Volume 8, Issue 1May 2015 josnr

Journal of Student Nursing Research

GlobalHealth

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Journal of Student Nursing ResearchUniversity of Pennsylvania School of Nursing

Volume 8, Issue 1, May 2015

RESEARCH

Globalization and the International Trade in Human Organs p.5Ariya L. Kraik

Female Genital Cutting in the KuraDistrict of Kenya: Health Implications of a Cultural Practice p. 10Stephanie S. Foster

Globalization on Health p. 13Jennifer M. Israelite

Cultural Influences on the Spread ofEbola in Western Africa p. 19Sarah Voisine

REFLECTIONS

Penn Nursing Study AbroadReflections: Guatemala, England, and Australia p. 23Jennifer Toth, Katelyn Ward, and Jane Chung

A Spanish Nursing Student’s Experiencein Scotland p. 28Jorge Riquelme, University of Alicante, Spain

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President’s Message

Dear JOSNR Readers, My name is Sarah Voisine, and I am the current President of the Organization of Student Nurs-ing Research (OSNR). I would like to thank you for taking the time to read through the eighth edition of the Journal of Student Nursing Research. This journal has been produced annually since 2007 by un-dergraduate nursing students at the University of Pennsylvania. The mission of the journal is to engage students in research by encouraging participation in research, spreading awareness of nursing research, and providing an opportunity for students to write about topics that fit their personal nursing interests. This year, the journal’s topic was chosen with the University of Pennsylvania’s Theme Year initiative in mind. Global health aligns well with the university-wide Year of Health program and is also very relevant in today’s world. The news is frequently dominated by global health topics ranging from ebola to measles to telemedicine. It is important to focus attention on a few of the many health issues facing people all over the world and get University of Pennsylvania students and nursing students worldwide engaged in these issues. We also included study abroad essays from University of Pennsylva-nia nursing students to highlight the experience of nursing in a different country and culture. Our school’s motto is “Care to Change the World.” This journal seeks to provide nursing re-search on global health issues and aid nursing students in gaining the knowledge they need to begin to change the world. We would like to thank each author for their dedication to JOSNR over the past few months, as we could not produce this journal without their passion and hard work. We hope that you as a reader enjoy the articles and are inspired to get involved in learning more about global health nursing.

Sarah Voisine2014-2015 PresidentOrganization of Student Nursing Resesarch

The Organization of Student Nursing Research (OSNR) is a organization at the University of Pennsylva-nia School of Nursing that encourages students to get involved in research. It is a forum for students to voice their views on current nursing topics and serves as an opportunity for students to publish their work in our student-run research journal, The Journal of Student Nursing Research.

Students in undergraduate nursing programs are invited to submit their work to the journal. Submissions may be 3,000 words in length, and formatted in APA style with a references list. If you are interested or have any questions, please e-mail us at OSNR.Penn@Gmail.com.

JOSNR Online at Penn Libraries repository.upenn.edu/josnr/OSNR at Penn Nursing www.nursing.upenn.edu/osnr

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Globalization and the International Trade inHuman OrgansAriya Kraik

The International Trade in Human Organs Over the course of the past half-cen-tury, Western medicine has made incredi-ble advances in the field of primary human organ transplantation, including complex procedures involving multiple organs. Un-fortunately, demand for these medical inter-ventions long ago outstripped the supply of organs available for transplantation. Prof-iteers have stepped into this market gap, as participants in an international organ trade that some concerned writers have styled “transplant tourism” (Budiani-Saberi & Delmonico, 2008). The World Health Or-ganization estimated that, in 2004, 10% of kidney transplants worldwide were performed for patients from developed countries who travelled abroad to purchase organs (Jafar, 2009). Though the extent of human organ trafficking is difficult to accurately assess due to its hidden and mostly unregulated nature, the past few years have seen a sharp rise in media reports relating to organ trafficking and unethical organ procurement involving individuals in India, Pakistan, Turkey, and Brazil (Jafar, 2009). The issue is not simply the commercialization of body parts and the resulting black market for human organs. Rather, further to the trend of globalization, it is about the apparent exploitation of the world’s poor by wealthy individuals in the developed nations.

1.The Foundation of the Issue:The Commodification of Organs, Influenced by Cultural and Ideological Globalization The advent of organ transplantation can be traced to the 1970s. Since then, trans-plantation has become a staple of modern medicine, and academics have pointed to ad-vancements in the medical field as the critical factor in this evolution. Prior to the devel-

opment of immunosuppressive drugs, organ donation needs were almost exclusively met by relatives of patients (Harrison, 1998). Giv-en that success rates of transplant operations were low and only slightly improved when donors and recipients were genetically related, organ transplantation was not a reliable med-ical intervention and, accordingly, there was no demand for other sources of organs. The development of antirejection drugs in the 1980s expanded the population of potential organ donors, widening the possibilities for organ transplantation and fuelling demand for organs. Following the elimination of this most significant impediment to transplanta-tion, the medical community fully embraced the practice. This wave of innovation and de-velopment within medicine has continued to influence organ transplantation, and has per-mitted the rise and growth of the internation-al human organ trade. In September 2000, for example, the Eurotransplant International Foundation, a non-profit organization dedi-cated to encouraging and coordinating organ transplants, expanded criteria for transplant waiting lists to include “medical margins”, i.e. patients older than 70 years of age, positive for HIV and hepatitis C, and those immuno-logically prone to rejection (Scheper-Hughes & Wacquant, 2002). Through the years, markets have responded to the changes in supply and demand for organs caused by changes in medical innovation, practice, and bioethical values. Critically, the procurement of or-gans shifted from live and cadaver donation sources, without monetary recompense, to the commercialization of body parts and the creation of a marketplace for organs. In her text Commodifying Bodies, Nancy Schep-er-Hughes, one of the world’s foremost ex-perts on organ trafficking, notes that today’s

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global economy “view[s] and treat[s] the body as an object…as a ‘commodity’ that can be bartered, sold or stolen in divisible and alienable parts” (Schep-er-Hughes & Wacquant, 2002, p. 1). This has fallen out of the global shift towards liberalized trade, but can be starkly seen at the level of the individual. Scheper-Hughes summarizes this transition in her summary of a 1999 research study in South India centred on interviews with local women who sold their kidneys: “A decade ago, when townspeople first heard through newspaper reports of kidney sales in the cities of Bombay and Madras, they responded with predictable alarm. Now…some of these people speak as matter of fact about when it might be necessary to sell a ‘spare’ organ. Globalization has encouraged the development of new forms of “debt peonage” in which the commodified and fetishized kidney occupies a critical role as collateral” (2002, p. 70).

2. The Birth of the Issue: How Economic & Political Globalization Propagated Transplant Tourism & the Organ Trade While the growth of transplant medicine helped create the framework for the commodifi-cation of human organs, the impetus for the de-velopment of a global organ trade is rooted in the economic drivers of supply and demand. Even with living donation practices across the globe, the supply of donated organs remains insufficient to meet demand. For example, in the United States the average waiting time for a kidney transplant is three to five years, and over 10,000 patients die annually waiting for an organ (Beard & Kaserman, 2013). In large measure, this imbalance is both an artifact of an aging population and a product of unhealthy lifestyle choices among those who inhabit the devel-oped world. Consequently, health systems are un-able to absorb the growing numbers of the critically ill, causing those who are impatient or ineligible for local transplant lists to seek treatment elsewhere. This has precipitated the emergence of transplant tourism and organ trafficking. Medical tourism, the practice whereby wealthier citizens from highly developed countries elect to travel to poorer countries to receive med-ical services at a reduced cost, is estimated to be a 40 to 60 billion dollar business that continues to

grow 20% annually (Horowitz, Rosensweig & Jones, 2007). Transplant tourism, however, is a perversion of this model of global health services; it is the ob-taining of an organ through illegally or unregulated means outside of a patient’s home country (Shiza-mono, 2007). Transplant tourism and the rise of the in-ternational organ trade have arisen due to a com-plex interplay of forces. Medical advances are an influencing factor, “in tandem with the spread of global capitalism and the consequent speed at which patients, technologies, capital, bodies and organs can now move across the globe” (Scheper-Hughes & Wacquant, 2002, p. 3). What is especially troubling, however, is that one now routinely sees substantial numbers of individuals in the developing world who are “exposed to the influence of traffickers and crim-inal networks” (Khooshie Lal Panjabi, 2010, p. 56). Essentially, forces of globalization have shrunk the world so that “for organized crime, the whole world is one marketplace” (Khooshie Lal Panjabi, 2010, p. 21).

3. Perpetuating the Issue: Global Socioeconomic Inequities The illegal trade in human organs is founded upon global socioeconomic inequality and is framed by issues of wealth, gender, ethnicity, and social class. The global human organ trade is a flow from developing to developed countries, thereby creat-ing organ-importing and organ-exporting nations, but more fundamentally it is a flow of organs “from poorer to more affluent bodies, from black to white ones, and from females to males” (Scheper-Hughes, 2002, p. 70). In organ trafficking, however, issues of race and gender are always underscored by econom-ic disparities. Organ donors are typically disenfranchised individuals who are motivated to sell their organs to escape crippling financial debt and poverty, while recipients of traded organs are more likely to be wealthy, as traded organs tend to come at a consid-erable cost (Shimazono, 2007). The discovery of an organ trafficking syndicate in India, considered to be “the mother of all scandals in human organ trafficking”, revealed that most organ sellers were impoverished migrant labourers who were paid between $500 to $1,000 for a kidney, while the kidney recipients were charged between $100,000

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and $200,000 for the transplant procedure (Aronow-itz, 2009). Equally, research has revealed a strong linkage between low-income nations and a greater willingness of poor people in those countries to sell their organs (Harrison, 2006). “Today the spare kidney represents every man’s last economic resort, one’s ultimate collateral” (Scheper-Hughes, 2002, p. 70).

Searching For a Global Solution Though globalization has played a consider-able role in creating and shaping the illegal trade in human organs, it may also yield solutions to miti-gate the problem. The globalization of healthcare services and the global nature of health argue in favour of the need for the existence of an organiza-tion to regulate and set standards for global health practices worldwide. Both the United Nations (UN) and the World Health Organization (WHO), an agency of the UN, have released official positions on the matter. The UN regards organ trafficking as being a “global injustice of using a vulnerable segment of a country or population as a source of organs (vulnerable defined by social status, ethnic-ity, gender or age)” (Budiani-Saberi & Delmonico, 2008, p.925). Similarly, the WHO has stressed the need to “protect the poorest and vulnerable groups from ‘transplant tourism’ and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs” (World Health Assembly, 2004). Against the backdrop of globalization, these international groups are taking the necessary first step leading to positive change. Unfortunately, the UN and WHO have limited ability to enforce the compliance of nation states with their stances on global issues. They have not succeeded in stemming the growth of transplant tourism and have been charged with not being “forceful in condemning both the use of direct financial incentives to increase the number of organs for transplant and commercialized tissue op-erations” (Jafar, 2009, pp. 1147, 1151). At a national level, legislation targeted at the organ trade and traf-ficking tends to be lacking or insufficient, particular-ly in organ-exporting countries. Though the sale of organs has been made illegal in Colombia, India and Pakistan, these nations remain significant sources of organs globally (Aronowitz, 2009; Jafar, 2009).

Despite the lack of cohesive global efforts and effective regulation to restrict the international organ trade, the global community has taken pre-liminary steps towards addressing the issue. In 2008, a meeting of 152 participants from 78 countries at the Istanbul Summit on Organ Trafficking and Transplant Tourism produced the Declaration of Istanbul, a document that describes the issues relat-ed to organ trafficking and transplant tourism, and proposes ethical, universal approaches for managing organ donation and transplantation. Ultimately, the Declaration was intended to “reinforce the resolve of governments and international organizations to develop laws and guidelines to bring an end to wrongful practices”, and to demand transparent regulatory oversight and international accountabil-ity to ensure safe practices (Steering Committee of the Istanbul Summit, 2008). Since its creation, the Declaration has resulted in new legislation in or-gan-donating and organ-importing countries that is believed to have shown some success in curbing unsafe and unethical organ donation practices (Danovitch & Al-Mousawi, 2012; Boas et al., 2015). The Declaration of Istanbul represents the first global effort to define issues relating to international organ trade, with the understanding that “an essen-tial first step in combatting such issues is to describe them precisely” and is an important step in a global solution to addressing the international organ trade (Steering Committee of the Istanbul Summit, 2008). Nevertheless, continued global efforts are necessary to effectively ensure the safety of organ donation practices and the protection of vulnerable people.

Strategies to Address the Issue While the scope of the international or-gan trade cannot be accurately determined, most global authorities agree that the rate of organ traf-ficking growth has increased over time (Khooshie Lal Panjabi, 2010). Given that the human organ trade involves an assortment of issues and external pressures, any attempt to ameliorate the issue will require a comprehensive, multi-pronged approach. Logically, the best place to start would be a system of regulation and control, twinned with efforts to address the demand and supply of human organs. The international organ trade has thrived under the weak legislation that speaks to organ trafficking practices worldwide.

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1. Establishing a System of Control Beyond the donors and recipients of organs directly involved in any transfer, there is a coterie of intermediaries complicit in the process as active participants—individuals who recruit donors and broker the arrangement, health providers involved in the transplantation procedure, and authorities who are either negligent or wilfully blind. Since the proper response to criminal activity is criminal sanction, involvement in organ trafficking should be criminalized. It is important that stronger legis-lation against involvement in the organ trade be established at a national level, in both organ import-ing and exporting nations. Failing a coherent global effort, the international organ trade will adapt by flowing through different export and import coun-tries. As an alternative to outright prohibition, a number of economists propose that the only effec-tive and sustainable way to prevent the exploitation of vulnerable persons in the organ trade is to legally regulate the activity and related levels of compen-sation. Some countries have created such systems, controlling the market by refusing donation to foreign nationals. The ethics and fairness of such a system have been challenged. Research indicates that, in the long-term, regardless whether the organ market is regulated or not, living organ donors already face health problems, economic hardship, unemployment and a poorer standard of living; the financial motivation that drives their donation is typically not relieved by selling an organ (Khooshie Lal Panjabi, 2010). On the other side of the argu-ment, economists opposed to a regulatory approach note that the use of fixed prices for donated organs will inevitably yield a lower financial return to do-nors than could potentially be received in an unreg-ulated commercial marketplace (Jafar, 2009).

2. Organ-Importing Countries: Addressing Recipi-ent Demand A February 2012 article in the British news-paper The Guardian, written from the perspective of an organ-importing country, accurately assessed transplant tourism as a global problem grounded in “a local shortage” (Sugg, 2012). Seen from this per-spective, it is arguable that issues of demand must be addressed first at a local level, rather than global-ly. Practically, developed nations can immediately

address domestic organ shortages by expanding donation pools and should reduce demand through the promotion of better health among the citizens. Several European countries have seen suc-cess in the implementation of national systems of default organ donation where all deceased individ-uals are considered organ donors unless they “opt out” in writing during their lifetimes. Countries that operate a system of presumed consent – such as Spain, Norway and Belgium – see reduced organ shortages and a majority of organ donations from deceased donors rather than live donors (Abou-na, 2008). Meanwhile, critical shortages of organs plague countries that favor a national “opt-in” poli-cy, like the United States. A less immediate solution to controlling de-mand for organs in organ-importing countries is to tackle the underlying cause of demand. The recent global increase of cardio-metabolic disease – the collective impact of diabetes, cardiovascular disease and obesity – that necessitates severe intervention, like transplantation, is rooted in unhealthy, West-ern lifestyles. The leading contributors to kidney disease, for example, are diabetes and hypertension, preventable medical conditions that can be slowed with early treatment and identification. Health pro-motion campaigns and disease screening have been shown to considerably reduce the progression and onset of these diseases.

3. Organ-Donating Countries: Addressing Donor Supply Most solutions to the problem of the inter-national organ trade focus upon organ recipient demand, or attempt to control the spread of the black market through more stringent legislation. It is less common to see any focus upon the individu-als who choose to sell their organs, mostly because this ends in a swamp of global socioeconomic disparities that have no easy solution. It is clear that the international trade in organs is underpinned by an economic divide that fuels the exploitation of impoverished and disadvantaged individuals. Stated otherwise, the problem of organ trafficking is a very human problem. As such, if the problem is to be ameliorated, there needs be a way to tip the balance in favour of organ donors. One way to do this would be to empower them financially. In this regard, microfinance—the provision of small loans

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to the poor to enable them to establish income-gen-erating activity and achieve self-sufficiency—has gained popularity in recent decades as a tool to alleviate poverty (Bateman, 2011). If scalable, this could be an important step towards mitigating so-cioeconomic inequalities. To be most effective, such an effort would require a coordinated effort between governments and international advocacy organiza-tions.

Conclusion Supported by the rising tide of globalization and advances in medical science, the trafficking in human organs often sees unhealthy, wealthy West-erners taking advantage of the destitute in develop-ing nations. Yet, much of this problem is controlla-ble at its source. That is, if individuals simply turned to healthier lifestyles involving better diets and ex-ercise, the illicit organ transplant industry would be greatly diminished. Practically, and from the stand-point of taking individual responsibility, this is an easier fix than a hope for the amelioration of poverty in donor nations. Moreover, Western nations could increase the domestic supply of healthy, replacement organs through campaigns to promote donor activ-ity. Combined with the threat of criminal sanctions for participants, including organ recipients, the global practice would suffer the same scrutiny and approbation as the illegal sex and drug trades.

ReferencesAronowitz, A. A. (2009). Human trafficking, human misery, the global trade in human beings. Westport, CT: Praeger Publishers.

Abouna, G. (2008). Organ shortage crisis: Problems and possible solutions. Transplantation Proceedings,40, 34-38. doi: 10.1016/j.transproceed.2007.11.067

Bateman, M. (2011, March). Microfinance as a development and poverty reduction policy: Is it everything it’s cracked up to be?. Over-seas Development Institute Background Note, Retrieved from http://www.odi.org.uk/sites/odi.org.uk/files/odi-assets/publications-opin-ion-files/6291.pdf

Beard, T., & Kaserman, D. (2013). The global organ shortage: Eco-nomic causes, human consequences, policy responses. Redwood City, CA: Stanford University Press.

Boas, H., Mor, E., Michowitz, R., Rozen-Zvi, B., & Rahamimov, R. (2015). The Impact of the Israeli Transplantation Law on the So-cio-Demographic Profile of Living Kidney Donors. American Journal Of Transplantation, 15(4), 1076-1080. doi:10.1111/ajt.13090

Budiani-Saberi, D., & Delmonico, F. (2008). Organ trafficking and transplant tourism: A commentary on the global realities. Amer-ican Journal of Transplantation, 8, 925-929. doi: 10.1111/j.1600-6143.2008.02200.x

Harrison, T. (2006). Frontiers of the market: Commodifying human

body parts. In G. Laxer & D. Soron (Eds.), Not for sale: Decommodify-ing Public Life (1 ed.). Toronto, Canada: University of Toronto Press.

Harrison, T. (1998). Globalization and the trade in human body parts. Canadian review of sociology/Revue canadienne de sociologie, 36(1), 21-35. doi: 10.1353/sais.2002.0022

Horowitz, M., Rosensweig, J., & Jones, C. (2007). Medical tourism: Globalization of the healthcare marketplace. Medscape General Med-icine, 9(4), 33-33. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234298/

Jafar, T. (2009). Organ trafficking: Global solutions for a global problem. American Journal of Kidney Diseases, 54(6), 1145-1147. doi: 10.1053/j.ajkd.2009.08.014

Khooshie Lal Panjabi, R. (2010). The sum of a human’s parts: Global organ trafficking in the twenty-first century. Pace Environmental Law Review, 28(1), 1-144. Retrieved from http://digitalcommons.pace.edu/pelr/vol28/iss1/1

Scheper-Hughes, N., & Wacquant, L. (2002).Commodifying bodies. (1 ed.). London, Great Britain: SAGE Publications.

Scheper-Hughes, N. (2002). The ends of the body: Commodity fetish-ism and the global traffic in organs. SAIS Review, 22(1), 61-80. doi: 10.1353/sais.2002.0022

Steering Committee of the Istanbul Summit. (2008) Organ trafficking and transplant tourism and commercialism: the Declaration of Istan-bul. The Lancet, 372(9632), 5-6. doi:10.1016/s0140-6736(08)60967-8

Sugg, R. (2012, February 16). Organ donations: A local shortage and a global problem. The Guardian. Retrieved from http://www.guardian.co.uk/commentisfree/2012/feb/16/organ-donations-local-short-age-global-problem

World Health Assembly, 57th Meeting. Agenda item 12.14 (2004) [Human organ and tissue transplantation]. 2004. Retrieved from: http://www.who.int/transplantation/en/A57_R18-en.pdf

ARIYA L. KRAIK is a student at the Uni-versity of Pennsylvania in the Nursing & Health Care Management dual-de-gree program. She will graduate in May 2015 with a BSN from the School of Nursing and a B.Sc. Economics from the Wharton School.

Female Genital Cutting in the Kuria Districtof Kenya: Health Implications of a Cultural PracticeStephanie S. Foster

Abstract Female Genital Cutting (FGC), any process which alters the female genitalia for non-medical purposes, continues to be a health concern in many areas of the world. The Kuria population in Kenya, of which 96% of women are subject to this dangerous custom, is the focal point of this discussion on FGC. For purposes of clarity, this paper will refer to women who have had female genital cutting procedures performed as FGC wom-en, and those who haven’t as non-FGC. The presented information is the result of a com-prehensive literature review on general FGC practices as well as practices specifically in the Kuria population. First, this paper will define the issue, its prevalence, and the four cate-gories of procedures. It will then explain the cultural significance of FGC. An overview of associated health risks juxtaposes the cultural meanings, demonstrating the stark disconnect between the societal values attributed to FGC and the health outcome realities. The paper will include details about current and previ-ous attempts of outsiders to abolish FGC, and describe the failure of these outsiders’ efforts to impose change within the local community. The paper seeks to demonstrate through this analysis that future global health practitioners are not only responsible for ending this bla-tant violation of human rights, but that efforts must be directed in a way that is culturally meaningful and supported by the Kurian soci-ety.

Female Genital Cutting in theKuria District of Kenya

The World Health Organization (WHO) defines female genital cutting (FGC) as, “procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons” (WHO, 2012). There

are no health benefits of these types of pro-cesses, but a plethora of associated problems. Every day, 8000 girls are at risk of undergo-ing FGC, and it is estimated that 100-140 million girls and women are living with its consequences (Momoh, 2010; WHO 2012). It is practiced widely in 28 African countries, as well as some Middle Eastern and Asian countries and Brazil. In particular, this paper focuses on the Kuria community in western Kenya, where 96% of the female population has undergone FGC (Oloo, Newell-Jones, & Wanjiru, 2011). Despite copious research of FGC’s detrimental outcomes, the internation-al community still allows this practice to oc-cur, failure to act often blamed on discomfort interfering with cultural traditions. However, FGC is seen as a violation of human rights in some cultures and is a severe health concern and as thus its eradication must become a priority for activists across the globe. The WHO delineates four types of FGC. Clitoridectomy is the partial or total removal of the clitoris or only the prepuce1. Excision is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Infibulation, the most severe form which accounts for approximately 15% of FGC procedures, is a narrowing of the vaginal opening created by cutting and repositioning the labia minora or

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1 It is important to note the controversy elicited by this definition, because many scholars maintain that exclu-sive removal of the prepuce (clitoridotomy) is analo-gous to male circumcision and should not be vilified. People from communities where only clitoridotomy is performed, such as Nigerian scholar Steve Nwabuzor, note that the condemnation of this traditional practice by the western community simply because it does not align with their cultural norms leads to estrangement between activist groups and the populations they hope to serve (as cited in Nnamuchi, 2012 p. 95).

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labia majora, with or without removal of the clito-ris (WHO, 2012). Amongst the Kuria population, about 13% of FGC cases were infibulations (Oloo et. al, 2011). The fourth category is designated for all other harmful procedures to the female genita-lia for non-medical purposes including pricking, piercing, incising, scraping and cauterizing (WHO, 2012). Typically, FGC processes are performed by a respected member of the community without any anesthetics (U.S. Office on Women’s Health, 2009). Girls undergo the procedure in their pre-adolescent years, the exact time being determined by a Council of Elders known as the inchaama (Prazak, 2007).

Cultural Factors Propagating FGC FGC continues to be practiced extensively in the Kuria district because it is so deeply ingrained into their traditional society. When the inchaama has determined (through a magical divination pro-cess) that the time is right for this initiation, thou-sands of girls and boys of age gather to partake in the ceremony. There are special garments (kangas), dances, and strict regulations accompanying the rit-ual. After the procedure is completed, the “initiates” are kept in isolation while they recuperate—this pe-riod is tellingly known as okooroka, which translates literally as “to vomit”— and a grandiose, celebratory feast is held afterwards (Prazak, 2007). More important than the physical manifes-tations of the ceremony, however, are the symbolic implications. “[P]arallel to the cutting of the umbil-ical cord when a child is born,” the female genitalia ritual signifies the transition of a child into adult-hood (Prazak, 2007). John Mbiti (1990), dubbed the father of contemporary African theology, ex-plains, “The physical pain which the children are encouraged to endure, is the beginning of training them for difficulties and sufferings of later life” (p. 120). The procedure is also thought to limit sexual promiscuity, as demonstrated by this declaration of an inchaama member: “The women [from a neigh-bouring community] are not circumcised that’s why they are free with their bodies and that’s why they have higher cases of HIV and AIDs amongst them” (as cited in Oloo et. al, 2011). FGC is considered a sign of purity, and women without it are considered dirty. Non- FGC girls are cruelly deprecated and ostracized in the community. As expressed by a stu-dent in the Kenyan newspaper Daily Nation, “When

I joined class six, I felt that I needed to be circum-cised so I could feel like the other girls. I desperately wanted to belong to their group. Didn’t want to continue being a child” (as cited in Ondiek, 2010). A girl who doesn’t undergo FGC has vir-tually no chance of getting married, and shame is reflected on her family. There is also a myriad of superstitions associated with non-FGC women, including that the external genitalia is unclean and can cause infant death during delivery, that the clitoris is poisonous and will kill a man if he comes in contact with it, or that any child who walks over a spot on which a non-FGC woman has urinated will die (Bryan, 2000; Ondiek, 2010; U.S. Office on Women’s Health, 2009). It is these notions which propagate this custom and in order for its successful elimination, FGC must be analyzed contextually.

Health Consequences of FGC The short and long term health implications of FGC are numerous and severe. Short term effects include intense pain, hemorrhage, tetanus, septic shock, urine retention and infection (U.S. Office on Women’s Health, 2009). According to research done by Public Health Specialist Dr. Comfort Momoh, 10% of girls and women die from these short term consequences (Momoh, 2010). The offenses con-tinue in the long term with FGC causing recurrent bladder or urinary tract infections, cysts, infertility, and the need for future surgeries (U.S. Office on Women’s Health, 2009). FGC doubles the risk of maternal death during childbirth, and the risk of having a stillborn child increases three to four fold (Momoh, 2010). The majority of procedures (82%) are performed by people with no medical training and the use of unsterilized equipment and unsani-tary conditions have been responsible for the spread of human immunodeficiency virus (WHO, 2012; Prazak 2007). Sexual activity is extremely painful for most FGC women, and in a society in which women are expected to be unquestioningly sub-missive to their husbands they must suffer this pain for years. There are also tremendous psychological effects of the traumatic procedure, with some wom-en reporting resultant depression or post-traumatic stress disorder (Momoh, 2010).

Steps towards FGC Eradication Efforts to eliminate FGC in Kenya date

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back over a century with British missionary lead-ers in 1906 being the first to protest. However, the Kenyans perceived this criticism as another way in which the colonial powers were subjugating their culture and responded defiantly, actually increasing FGC prevalence (Ondiek, 2010). Today, it is largely non-governmental organizations, community based organizations and churches that have taken up the cause to eradicate FGC. Namely, organizations such as ActionAid Kenya, GTZ , the Pentecostal Fel-lowship of America, and the Seventh-Day Adven-tist Church currently serve the Kuria community (Prazak, 2007). They have developed “Alternative Rites of Passage” (ARPs) to note the transition to womanhood without the genital cutting process. These programs involve education on “culture, female genital mutilation, empowerment, adoles-cence, legal rights, youth peer counseling, effects of FGC, myths and misconceptions, religion, commu-nication, problem handling, [the] reproductive sys-tem, peer pressure, STD/HIV, and gender” (p. 24). In addition, the ARP in the Kuria community offers a “safehouse”/camp for the duration of the initiation period open to girls from 8-20 years old who are at risk for FGC (Prazak, 2007). While more successful in some other regions practicing FGC, research shows that ARPs have currently not been accepted as a replacement for FGC by the Kuria society. Many complaints were voiced about the recruitment for the ARP camps, claiming that people with connections to NGOs were more likely to attend. Even more troubling is that the camps fail to provide ongoing support to the girls after they leave (Prazak, 2007). Statistics from the 2004 initiation process in the Kuria com-munity showed that of the 289 girls who attended the ARP camp to avoid FGC, “…all but eighty of those girls were forced by their relatives or pressured by their peers to [later] undergo the cutting” (p. 25). Research conducted by Oloo et. al (2011) concludes that, “[a]ll involved in the Rescue/ARP Camps - or-ganisers, parents and previous participants – recog-nized that they would not be the solution to FGC on their own, even if well resourced” (p. 21).

Duty of Global Health Practitioners Today While the outlook seems bleak, we as fu-ture healthcare professionals have a moralistic responsibility to eradicate this process. However,

as demonstrated by the current failure of ARPs, the movement must be powered from within the communities and championed by respected native leaders. As Stanford-educated anthropologist Ellen Gruenbaum (2005) notes, “To women of the regions where forms of [FGC] are practiced, the Western feminist leaders who displayed ethnocentric polem-ics to denounce the harmful traditional practices were attacking the right of African and Middle Eastern women to determine the targets and tim-ing of their struggles” (p.89). A culturally-sensitive solution can only be accomplished through contin-uous, non-judgmental, non-shame based educa-tion. Long-term, discussion-filled relationships and health education in FGC communities should be a priority for global health leaders, but must be han-dled tactfully. Attitudes cannot be forced to change, but factual and sensitive education is essential to protect the health, rights, and integrity of women against the inhumane practice of female genital cut-ting.

ReferencesBryan, J. (2000). Female genital mutilation. Retrieved from http://english.emory.edu/Bahri/FGM.html

Gruenbaum, E. (2005). Feminist activism for the abolition of FGC in Sudan. Journal of Middle East Women’s Studies 1(2) 89-111. doi: 10.1353/jmw.2005.0033

Mbiti, J. (1990). African religions & philosophy (pp. 120). Retrieved from http://books.google.com/books?id=eTUpo9lHfYC&printsec=frontcover&d-q=african+religions+and+philosophy&hl=en&sa=X&ei=2XaHUPyxB9LU0g-G20ICoDA&ved=0CC8Q6AEwAA

Momoh, C. (2012, June 8). Current issues: Female genital mutilation. Trends in Urology, Gynaecology, & Sexual Health, 15(3) 11-14. doi: 10.1002/tre.142

Nnamuchi, O. (2012). Circumcision or mutilation - Voluntary or forced exci-sion - Extricating the ethical and legal issues in female genital ritual. Journal of Law and Health, 25. Retrieved from http://heinonline.org/HOL/Page?collec-tion=journals&handle=hein.journals/jlah25&div=6

Oloo, H., Newell-Jones, K., & Wanjiru, M. (2011, March). Female genital mutilation practices in Kenya: The role of alternative rites of passage—A case study of Kisii and Kuria districts. Retrieved from http://www.feedtheminds.org/downloads/FGM% 20Report_March2011.pdf

Ondiek, C.A. (2010, June). The persistence of female genital mutilation (FGM) and its impact on women’s access to education and empowerment: A study of the Kuria district, Nyanza province, Kenya. Retrieved from http://uir.unisa.ac.za/bitstream/handle/10500/4121 /dissertation_ondiek-c.pdf?sequence=1

Prazak, M. (2007). Introducing alternative rites of passage. Africa Today, 53(4) 19-40. doi:10.1353/at.2007.0030

U.S. Office on Women’s Health. (2009, December 15). Female genital cutting fact sheet. Retrieved from http://www.womenshealth.gov/publications/our-publications/fact-sheet/female-genital-cutting.cfm

World Health Organization. (2012, February). Female genital mutilation: Fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/

STEPHANIE S. FOSTER is a senior nursing student at the University of Pennsylvania with a minor in Global Health.

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Globalization on HeathJennifer M. Isralite

Introduction Global health focuses on the well-be-ing of the world’s population. A major con-tributing factor of global health is global-ization. Globalization has made the world a much smaller place and countries that once had little direct connection to Western indus-trialized nations are now in daily interaction with them (Eichenwald, 2014). This leads to increased movement of individuals and goods, and the global dissemination of infec-tious and noninfectious public health risks, all of which influence global health (De Cock et al., 2013). Engagement in global health is not simply a humanitarian concern but a priority for our collective wellbeing and for safeguard-ing our future (De Cock et al., 2013). The consequences of the world becoming more interconnected have both positive and nega-tive effects on global health as evidenced by the severe acute respiratory syndrome (SARS) outbreak in 2002-2003.

Positive Consequences Development and accessibility to vaccinations are major positive outcomes of globalization with regards to global health. Poliomyelitis, or polio, is an infectious viral disease that can affect anyone at any age by damaging a person’s nervous system (Centers for Disease Control and Prevention, 2014). Polio was one of the most feared diseases of the twentieth century and crippled more than 35,000 individuals in the United States each year on average (Centers for Disease Control and Prevention, 2014). In 1909 two Austrian physicians determined the causative agent of poliomyelitis (De Jesus, 2007). Globalization allowed this discovery to be communicated around the world. Two vaccinations were de-veloped by two American medical researchers as a result of this information being spread,

(De Jesus, 2007). Both were safe and shown to effectively immunize and protect against polio (De Jesus, 2007). Less than twenty years after the introduction of the oral vaccine, the trans-mission of polio was halted in 1979 (De Jesus, 2007). Soon the Pan American Health Orga-nization (PAHO) announced its goal to erad-icate poliovirus in the Western Hemisphere by 1990 (De Jesus, 2007). The target date was met thanks to the coordination between the continents in the Americas (De Jesus, 2007). The World Health Organization (WHO) also launched a global campaign to eradicate po-liovirus (De Jesus, 2007). The WHO’s Global Polio Eradication Initiative served to greatly reduce the number of documented cases of poliomyelitis worldwide (De Jesus, 2007). The eradication of polio could not have been accomplished without globalization. Devel-oped countries assisted developing countries with regard to administration and access to the polio vaccination. The quick spread of the vaccination was accomplished through the increased interconnectedness of the world, helping to improve global health. Other vaccinations such as the varicella, rotavirus, and meningococcal vaccine all contribute to global health and are positive consequences of globalization. Globalization has allowed individuals to seek medical treatment in other parts of the world. Throughout history, sick individuals have embarked on pilgrimages to find cures (Chen and Wilson, 2013). Individuals from developing countries travel to more developed countries for higher-quality medical services. In addition, individuals travel from developed countries to low or middle-income countries for more affordable procedures (Chen and Wilson, 2013). People travel to other coun-tries to seek medical help if treatments are not covered by health insurance in their home

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country, if the procedure or treatment is unavail-able, or if there are legal or cultural constraints in their home country (Chen and Wilson, 2013). This concept can be defined as medical tourism and improves the overall quality of care of the country due to higher standards for treating foreign pa-tients (Chen and Wilson, 2013). Further, families contribute to the local economy and healthcare workers trained elsewhere may repatriate to coun-tries of origin to work and improve local access and quality of care (Chen and Wilson, 2013). Not only does medical tourism benefit the patient, but it also benefits the economy and helps the healthcare infra-structure. Globalization has made medical tour-ism possible. Patients can have successful kidney transplants or partake in a clinical research trial for a developing chemotherapy drug that may not be available in their home country. Over 40% of unre-lated stem cell transplants worldwide involve donors from a different country (Chen and Wilson, 2013). This demonstrates the importance of globalization with regard to medical treatment for individuals since the increase of travel allows one to receive care in a foreign country. Global health is an international concern. Many believe access to health is a human right and this belief has influenced the world to work together to decrease the spread of infectious diseases and im-prove international wellbeing (Fidler, 2004). In 1851 the first international sanitary conference was held to reconcile the need for standardizing quarantine procedures to prevent the spread of diseases with-out disrupting international trade (Clift, 2013). This led to the establishment of PAHO and the Office of International d’Hygiène Publique (OIHP) which both aim to help control the spread of infectious dis-eases (Clift, 2013). The World Health Organization (WHO) was founded in 1948 and still exists today (Clift, 2013). A main accomplishment of the WHO was successfully eradicating smallpox after creating the Intensified Smallpox Eradication Programme in 1967 (Clift, 2013). The mass vaccination strategy eventually proved victorious as the last recorded case of smallpox occurred in Somalia in 1979, only twelve years after the implementation of the pro-gram (De Jesus, 2007). Core functions of the WHO include:

Providing leadership on matters critical to health and engaging in partnerships where

joint action is needed; shaping the research agenda and stimulating the generation, transla-tion and dissemination of valuable knowledge; setting norms and standards, and promoting and monitoring their implementation; articu-lating ethical and evidence-based policy op-tions; providing technical support, catalyzing change, and building sustainable institutional capacity; monitoring the world’s health situa-tion and assessing health trends (Clift, 2013).

Creating an international organization helps the governance of global health. The International Health Regulations (IHR) is the only set of in-ternational legal rules concerning the control of infectious diseases (Fidler, 2004). The objective of the IHR is to ensure maximum security against the international spread of diseases by requiring WHO member states to notify the WHO of disease out-breaks (Fidler, 2004). The regulations also require WHO member states to maintain certain public health capabilities at ports and airports, which are centers for global trade and travel (Fidler, 2004). Further, the Global Outbreak Alert and Response Network (GOARN) was created as a network with-in the WHO which links individual surveillance and response networks that have been established throughout the world (Heymann, 2005). Set up in 1997 and formalized in 2000, the network now has over 120 surveillance and response partners world-wide (Heymann, 2005). Increased mutual awareness and surveillance of the spread of infectious disease is critical to determine risk factors, track disease outcomes, and develop international health system responses. Moreover, several organizations and agen-cies exist that work together to help improve and monitor certain diseases. For example, the Joint United Nations Programme on HIV/AIDS (World Health Organization, 2013) brings together efforts and resources of eleven United Nations system organizations to unite against AIDS (World Health Organization, 2013). Their mission is “to lead and inspire the world in achieving universal access to HIV prevention, treatment, care and support” (World Health Organization, 2013, p.1). The Global Alliance for Vaccines and Immunizations (GAVI) “brings together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s

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poorest countries” (GAVI, 2014, p.1). Unfortunate-ly 2.5 million deaths are reported annually from vaccine-preventable diseases (De Cock et at., 2013). UNITAID is another organization that helps with treatment and diagnostics of HIV/AIDS, tubercu-losis, and malaria in low-income countries and to make life-saving products more effective and afford-able in developing countries (World Health Orga-nization, 2013, p.1). All of these programs involve multiple countries working together to help improve global health and decrease health disparities within and between countries.

Negative Consequences Although there are many positive outcomes from globalization, there are also negative conse-quences on global health. For starters, the spread of disease is the result of rapid globalization and increased interconnectedness of the world. Eichen-wald writes, “…cargo comes from all over the world. Parasites or viruses in one country can now travel quite readily to another—whether inside a person or in shipments with seemingly innocuous items” (Eichenwald, 2013, p.22). The African malaria mosquito Anopheles gambiae migrated from western Africa on mail-boats that traversed the Atlantic in 3-4 days, due to globalization and increased tech-nology, and gained entry into Brazil in 1937 (McMi-chael, 2005). The mosquito species spread along the Brazilian coast and inland, and caused up to 50,000 deaths (McMichael, 2005). Likewise, McMichael writes, “studies have shown that Muslim pilgrims brought an epidemic strain of Neisseria meningit-ides from southern Asia to Mecca in 1987, where they passed it on to pilgrims from sub-Saharan Africa who subsequently initiated, after returning home, strain-specific epidemic outbreaks in 1988 and 1989” (McMichael, 2005, p.10). In addition, West Nile virus originated in Africa and arrived in New York in 1999 via an infected mosquito on an airplane (McMichael, 2005). West Nile virus then spread rapidly across the United States due to in-creased globalization and by early 2004 established itself as an endemic virus (McMichael, 2005). The dissemination of this virus soon reached Mexico where a state of emergency was declared (McMi-chael, 2005). Living in a rich country with a good healthcare system does not protect anyone from the dangers posed by newly emerging, life-threat-

ening infections (McLean et al., 2005). The travel of disease has been around since the beginning of time and globalization further spreads these infections and viruses. No matter where the microorganism originated from, everyone is at risk. Globalization has also negatively affected the climate instability of Earth. Over the last 200 years the accelerated development of human mate-rials has altered the composition of the atmosphere to an extent unprecedented in the 800,000-year record (Giegengack and Vita-Finzi). Global indus-trial production of CO2 from combustion of fossil fuel is further altering the chemistry of the atmo-sphere (Giegengack and Vita-Finzi). In addition, with development comes an increased standard of living. Brazilian farmers are burning down tropical rain forests to clear land to plough and Indonesians are converting their lush jungle into toothpicks in order for these countries to keep up with the rapid changes of the world and the increased standards of living (Barber, 1992). “Fast-swelling populations press upon the surrounding forests, grazing lands, and water supplies, and they inflict dreadful damage upon local environments” (Kennedy, 1993, p.324). Tropical deforestation, road building, irrigation, dam building, intensified crop and animal produc-tion systems, and pollution of coastal zones are all human-induced environmental changes that affect infectious disease risks (McMichael, 2005). The increased nutrient enrichment of coastal and estu-arine waters by phosphates and nitrates in run-off water enhances the growth of vibrio-harbouring phytoplankton and zooplankton (McMichael, 2005). In addition, the WHO estimates 6-7% of malaria in some parts of the world can be attributed to the climate change that has occurred during the past quarter of a century (McMichael, 2005). These climate changes due to globalization are reshaping the relations between humans and microbes and are creating an environment that allows infectious diseases to grow and spread rapidly. Bioterrorism is another negative conse-quence from globalization that threatens global health. Bioterrorism can be considered a form of mass destruction. Infectious diseases are capable of wiping out entire populations and societies. The Justinian Plague of 542AD devastated Constanti-nople and the Roman Empire (McMichael, 2005). Without smallpox, Cortes may not have conquered

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the mighty empire of the Aztecs (McMichael, 2005). European exploration and imperialism caused trans-oceanic spread of often-lethal infectious disease (McMichael, 2005). Many Native Ameri-cans died from exposure to these diseases and thus allowed Europeans to take over the land. Research on anthrax, a potentially fatal infection, as a bio-logical weapon began more than 80 years ago, and today at least 17 nations are believed to have biolog-ical weapon programs that include anthrax (Riedel, 2005). Anthrax is highly contagious and can destroy an entire city or region (Riedel, 2005). Riedel writes, “in 1970, a WHO expert committee estimated that an aircraft release of 50 kg of anthrax over an ur-ban, developed population of 5 million would result in 250,000 casualties, of whom 95,000 would be expected to die and an additional 125,000 would be severely incapacitated” (Riedel, 2005, p.236). The Biological Weapons and Toxins Convention of 1972 prohibited offensive bioweapons research and was signed by most countries, however, the former Soviet Union (FSU) and Iraq, both signatories of the convention, have subsequently acknowledged bioweapons research and production (Riedel, 2005). Despite international agreements, the threat of biological warfare agents continues to exist (Riedel, 2005). Infectious diseases are a greater national security threat than ISIS, Al-Qaeda and every other terrorist group combined (Eichenwald, 2014). If hu-manity perishes, chances are, an infectious disease will be the culprit (Eichenwald, 2014). Increased globalization makes a bioterrorist attack more possi-ble than ever before and could cause irreversible and detrimental effects on the health of global popula-tions.

SARS Case Study The SARS outbreak in 2002-2003 demon-strates both the positive and negative consequenc-es of globalization. On November 16th, 2002, a week after eating a wildcat, a 43-year-old male in Guangzhou, China presented with a fever, diarrhea, malaise, and myalgia for the past three days, and had no response to antibiotics (Zhong and Zeng, 2005). Eight people who had close contact with him developed similar pneumonia-like symptoms 8-10 days after his admission (Zhong and Zeng, 2005). At that time, no one had any idea what the diagnosis of this disease was and could only name it as ‘pneu-

monia with an unknown cause’ and then as ‘atypical pneumonia’ (Zhong and Zeng, 2005). By the end of March 2003, the patient was diagnosed with SARS by a rise in serum SARS-CoV IgG antibody (Zhong and Zeng, 2005). After the first report, reports of SARS increased, first in the cities of Guangdong, then in Hong Kong, and then in other cities in main land China (Zhong and Zeng, 2005). The epidemic of SARS in Hong Kong began with the visit of an in-fected physician from Guangzhou in mid-February 2003 (Zhong and Zeng, 2005). At least 16 visitors and guests at the hotel where he stayed came down with this illness (Zhong and Zeng, 2005). These in-fected individuals in turn spread the disease to other cities including Toronto, Singapore, and Hanoi and subsequently to more than 30 countries and regions across five continents (Zhong and Zeng, 2005). The quick spread of this disease illustrates the negative consequences of globalization. SARS is classified as a super-spreading event, where one case generated large numbers of secondary cases due to the per-son-to-person transmission (Anderson et al., 2005). One individual in Guangzhou China had detrimen-tal effects on the rest of the world due to globaliza-tion. In order to help decrease the rapid spread of this disease, the WHO became involved. They were informed on February 11th, 2003 about this mysterious syndrome (Peiris and Guan, 2005). On February 14th, the hospital authority and the de-partment of health in Hong Kong set up surveillance of cases (Peiris and Guan, 2005). After increased number of cases, the WHO had to respond quickly and on March 12th they issued a travel advisory warning against travel to affected regions (Peiris and Guan, 2005). Alert provided guidance for travel-ers, airlines and crew (Heymann, 2005). By March 17th, the WHO initiated a network of laboratories across the world to help establish the etiology of this new disease (Peiris and Guan, 2005). The network functioned through daily teleconferences exchang-ing information on patients and specimens being investigated on a real-time basis (Peiris and Guan, 2005). In addition, a secure website was established to post findings that could be shared by members within the network (Peiris and Guan, 2005). With success, the WHO laboratories were able to isolate the novel coronavirus associated with SARS by the end of March (Peiris and Guan, 2005). The full

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genetic sequence of the SARS-CoV was unraveled within weeks of its initial isolation providing the biological foundation for further research on anti-virals, vaccines and pathogenesis (Peiris and Guan, 2005). This led to the development of a laboratory diagnostic test and on March 28th a lab test for SARS was implemented worldwide (Peiris and Guan, 2005). The WHO also provided a case defi-nition of SARS which is a person presenting after November 1st 2002 with a history of high fever and cough or breathing difficulty, and one or more expo-sures during the 10 days prior to onset of symptoms (Anderson et al., 2005). Creating a definition helped improve worldwide surveillance of this disease as it spread rapidly. By July 5th 2003, about six months after the WHO became involved, the outbreak was formally declared as over (Peiris and Guan, 2005). The SARS outbreak reminded us that ‘Na-ture’ remains the greatest bio-terrorist threat of all (Peiris and Guan, 2005). It illustrated that we live in a global village and that emerging infectious dis-eases are not just threats to human health but can radically impact the economy and society as a whole (Peiris and Guan, 2005). This epidemic caused much “suffering, significant mortality, great disruption to social and work activities, and considerable eco-nomic losses” (Anderson et al., 20052, p. 80). Within weeks of SARS appearing in Hong Kong, a travel and business hub for the world, the disease had spread to affect over 8,000 patients in 26 countries across five continents (Peiris and Guan, 2005). The travel warning stopped tourism to the affected coun-tries, which in turn hurt the economy. In addition, there was suspicion that the virus was transmitted from ingesting wildcat. The Guangdong local gov-ernment and department of public health started to have strict control over the wildlife market, affecting many Chinese workers (Zhong and Zeng, 2005). Fortunately, the WHO was able to mobilize and coordinate a rapid global response that was essential in the understanding and controlling of SARS (Peiris and Guan, 2005). The WHO success-fully coordinated an international collaboration that included clinical, epidemiological, and laboratory investigations to control the expanding epidemic (Osterhaus, Fouchier, and Kuiken, 2005). To date, a SARS vaccine is still under research and the best treatment is cutting off the transmission route (Zhong and Zeng, 2005). Real-time information

made it possible for the WHO to provide specific guidance to health workers on clinical management and protective measures to prevent further spread since that is the best way to contain the disease (Heymann, 2005). The recommendation for travel-ers also helped stop international spread (Heymann, 2005). The control of this disease supports that globalization has positive effects on global health. Without the ability to communicate with individuals from around the world, the results of this epidemic could have been worse. There was also an integra-tion of traditional Chinese medicine and Western medicine that helped relieve dyspnea and malaise, and facilitated the resolution of pulmonary infiltra-tion (Zhong and Zeng, 2005). The incorporation of Western medicine was possible due to globalization. In addition, the willingness of the international community to form a united front against a shared threat showed another positive feature of a global-ized society (Heymann, 2005).

ConclusionThe SARS outbreak is one example of how global-ization can positively impact global health since this outbreak was contained in a relatively short amount of time. However, viral diseases pose a continual threat to human populations and global health (Holmes and Rambaut, 2005). As a result of globalization, human mobility and long-dis-tance trade have increased, larger cities girded with slums have become highways for microbial traffic, poverty perpetuates vulnerability to illnesses, and sexual practices, drug injecting, and intensified food production all create new opportunities for the spreading of diseases (McMichael, 2005). “Since we are living in larger populations and are becoming increasingly mobile it is inevitable that new viruses, like SARS-CoV, will appear in the future” (Holmes and Rambaut, 2005, p.23). Although the world suc-cessfully contained the SARS outbreak, infectious diseases will continue to emerge. Further investment in the study of viral evolutionary genetics is criti-cal to understanding fundamental aspects of viral emergence and may also play a role in predicting what diseases might emerge in the future (Holmes and Rambaut, 2005). In addition, the world needs to help eliminate health disparities both between and within countries. A clear correlation exists between countries’ gross domestic product and their health

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indicators (De Cock et al., 2013). Therefore a syn-ergistic engagement by all countries in this interde-pendent world needs to exist and replace the model of donors and recipients (De Cock et al., 2013). The world needs to unite in order to protect future gen-erations from infectious diseases.

ReferencesAnderson, R., et al. (2005). Epidemiology, Transmission Dynamics, and Control of SARS: The 2002-2003 Epidemic. SARS A Case Study In Emerging Infections (pp.61-81). New York: Oxford UP.

Barber, B. (1992). Jihad vs. Mcworld. The Atlantic Monthly Retrieved from https://upenn.instructure.com/courses/1237397

Centers for Disease Control and Prevention (2014, Jan 1). A Po-lio-Free U.S. Thanks to Vaccine Efforts. Retrieved from http://www.cdc.gov/Features/PolioFacts/

Chen, L., and Wilson, M. (2013). The Globalization of Healthcare: Implications of Medical Tourism for the Infectious Disease Clinician. Clinical Infectious Disease. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23943826

Clift, C. (2013). The Role of the World Health Organization in the In-ternational System. Working Group on Governance Paper 1 Retrieved fron http://www.chathamhouse.org/sites/files/chathamhouse/public/Research/Global Health/0213_who.pdf

Climate Crises in Human History: American Philosophical Society, Special Transactions (2014). Retrieved from https://upenn.instruc-ture.com/courses/1237397

De Cock, K., Simone, P., Davison, V., and Slutsker, L. (2013). The New Global Health. Emerging Infectious Diseases Retrieved from http://www.medscape.com/viewarticle/810402

De Jesus, N. (2007). Epidemics to Eradication: The Modern History of Poliomyelitis. Virology Journal 4(7) Retrieved from http://www.virologyj.com/content/pdf/1743-422X-4-70.pdf

Eichenwald, K. (2014). The Good News About the Great Ebola Panic. Newsweek Global 163(17) Retrieved from http://www.newsweek.com/2014/10/31/fear-infectious-disease-not-ebola-278505.html

Fidler, D. (2004). SARS, Governance and the Globalization of Disease. New York: Palgrave Macmillan.

GAVI (2014, Jan 1). About GAVI, the Vaccine Alliance. Retrieved from http://www.gavi.org/about/

Giegengack, R., and Vita-Finzi, C. Climate Change: Past, Present and Future.

Heymann, D. (2005). The International Response to the Outbreak of SARS, 2003. SARS A Case Study In Emerging Infections. New York: Oxford UP.

Holmes, E., and Rambaut, A. (2005). Evolutionary Genetics and the Emergence of SARS Coronavirus. SARS A Case Study In Emerging Infections. New York: Oxford UP.

Kennedy, P.(1993). Preparing for the 21st Century: Winners and Losers. The New York Review of Books. Retrieved from https://upenn.instructure.com/courses/1237397

McLean, A., et al. (2005). Introduction. SARS A Case Study In Emerg-ing Infections. New York: Oxford UP.

McMichael, A. (2005). Environmental and Social Influences on Emerging Infectious Diseases: Past, Present, and Future. SARS A Case Study In Emerging Infections. New York: Oxford UP.

Osterhaus, A., Fouchier, R., and Kuiken, T. (2005). The Aetiology of SARS: Koch’s Postulates Fulfilled. SARS A Case Study In Emerging Infections. New York: Oxford UP.

Peiris, J., and Guan, Y. (2005). Confronting SARS: A View from Hong Kong. SARS A Case Study In Emerging Infections. New York: Oxford UP.

Riedel, S. (2005). Anthrax: A Continuing Concern in the Era of Bioterrorism. Baylor University Medical Center Proceedings 18(3)Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200731/

UNAIDS: Joint United Nations Programme on HIV/AIDS (2013). Retrieved from http://www.un.org/youthenvoy/2013/08/unaids-joint-united-nations-programme-on-hivaids/

World Health Organization (2014, Jan 1). About UNITAIDS. Innova-tive Financing to Shape Markets for HIV/AIDS, Malaria, and Tuber-culosis. Retrieved from http://www.unitaid.eu/en/who/about-unitaid

Zhong, N., and Zeng, G. (2005). Management and Prevention of SARS in Chine. SARS A Case Study In Emerging Infections. New York: Oxford UP.

JENNIFER M. ISRAELITE is a senior nursing student from Phil-adelphia, PA. She is working in the medical intensive care unit at the Hospital of the University of Pennsylvania next year.

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Cultural Influences on the Spread of Ebola in Western AfricaSarah Voisine

Cultural Misunderstandings and the Spread of Ebola in Western Africa

The outbreak of Ebola hemorrhagic fever and the devastation it has left behind in Western Africa over the past few years has led to many questions about the virus among global health leaders. Health professionals are especially interested in how this disease spread so quickly and caused so much harm to the people of Western Africa. Many have turned to cultural practices and the general understanding of infection control in Guinea, Sierra Leone, and Liberia to help explain the unprecedented effect of the virus. These coun-tries and many others in Africa often connect illness with spiritual conflict and sometimes turn to natural or spiritual practices to help people return to a state of health (Hewlett & Amola, 2003). Also, a sophisticated under-standing of infection control procedures and the disease process itself is not always found in the villages and communities of Western Africa. Practices such as burials are not always performed under rigorous infection control protocols and public health agencies in the major cities of the affected countries are weak or non-existent (Kurtzman, 2014). Although the spread of the virus seems to be slowing down considerably, it is still important to an-alyze the reasons behind its pervasive trans-mission in order to prevent such devastation in the future.

History of Ebola Outbreaks Ebola is not a new disease in Afri-ca. The first reported case was in 1976 in the Democratic Republic of the Congo, a small country in Central Africa. Prior to the 2014 outbreak, there had been approximate-ly twenty-four known outbreaks of Ebola across Africa, centered in Gabon, Democratic Republic of the Congo, and Uganda (CDC,

2015). These outbreaks were on a much small-er scale than the 2014 outbreak of Ebola. The most severe outbreak before 2014 was in 1976 with 316 cases and 280 deaths. In comparison, the most recent Ebola outbreak has seen over 14,800 cases with 10,611 deaths (CDC, 2015). Many of the outbreaks started from a person handling the carcass of an infected animal, although epidemiologists could not identify a Patient Zero in every outbreak (Muyem-be-Tamfum et al., 2012). Animals known to carry the Ebola virus include monkeys, apes, and bats. The tropical climate in central and Western Africa is conducive to the spread of Ebola because of the biodiversity and humid weather. Once the virus was transmitted to a human, it spread from person to person via direct contact with bodily fluids. Past out-breaks were controlled with a combination of isolation, education, and global support for local public health agencies in the affect-ed country. Historically, treatment for Ebola mainly centered on supportive care such as hydration, replacement of electrolytes, and maintenance of blood pressure and respira-tory status (CDC, 2014). Blood transfusions from Ebola survivors were first given to pa-tients with Ebola in 1995 with a survival rate of 88%. These transfusions were meant to give passive immunity to patients via the Ebola antibodies in the survivor’s blood (Muyem-be-Tamfum et al., 2012). Currently, there is no vaccine or medication available to cure Ebola but scientists across the world are hard at work to design a better treatment for this virus.

Transmission of Ebola Ebola hemorrhagic fever is from a class of viruses known as the filovirus. It is found in primates and fruit bats and is trans-mitted to humans when they handle or eat

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animal carcasses or eat fruit touched by infected bats (Marais et al., 2015). Once humans are infected, the disease is spread through contact with blood or other bodily fluids or contaminated objects such as needles. Bodily fluids are defined by the Centers for Disease Control and Prevention as blood, urine, saliva, sweat, feces, semen, vomit, and breast milk (CDC, 2015). The fact that this disease is spread through bodily fluids makes it especially dangerous to treat. Some of the symptoms of Ebola include diarrhea, vomiting, and unexplained bleeding so healthcare practitioners and family members of Ebola patients must be extremely careful to avoid all bodily fluids while simultaneously providing sup-portive care to the patient. This requires the exten-sive use of personal protective equipment (PPE). According to the World Health Organization (2014), personal protective equipment for caregiv-ers of Ebola patients should cover all exposed skin and mucous membranes. WHO recommends a hood/head cover, knee-high waterproof boots, an apron, gown, gloves, an N95 mask, a face shield, and goggles (WHO, 2014). One challenge associated with this level of PPE is the removal process, as it is extremely important to avoid contamination during this process. While videos and posters are available for health care facilities, many of these resources were created after the Ebola outbreak had already grown to epic proportions. More basic infection control policies were also not always followed in African hospitals, leading to issues with disease containment early in the outbreak. For example, healthcare workers in a Guinea hospital were wash-ing their hands using pure chlorine bleach or water mixed with 2% chlorine, leaving their hands dry, cracked, and at a higher risk for exposure to the Ebola virus (Vallenas, 2015).

Cultural Factors Complicating the Spread of Ebo-la in Western Africa

Illness and Healing Practices African culture has long relied on spiritual influences to promote healing. For example, the Alcholi ethnic group of Uganda believes strongly in the power of jok, which are spirits or gods. When a family member becomes ill, the Alcholi ask tradi-tional healers to use their jok to communicate with the likely cause of the illness. Healing practices in-clude sacrifices to gods, removal of poisons around

the family’s house, and offering respect and prayer to the gods (Hewlett & Amola, 2003). During the 2000-2001 Ebola outbreak in Uganda, it was import-ant for aid workers to educate on medical interven-tions while also incorporating indigenous Alcholi healing practices into their care (Hewlett & Amola, 2003). In Gabon, the site of several Ebola outbreaks in the mid-1990s, local villagers referred to Ebola as “ezanga”. They went on to say, “Ezanga are bad human-like spirits that cause illness in people who accumulate [things] and do not share” (Hewlett & Hewlett, 2007). The notion that Ebola and other illnesses are caused by evil spirits can be dangerous from an epidemiological standpoint. Villagers at risk of contracting the illness may not be concerned or may not take appropriate precautions because they believe that they are “simple, generous people” and the evil spirits will not be a problem for them (Hew-lett & Hewlett, 2007). Furthermore, those infected with Ebola are socially isolated and stigmatized in their community because villagers connect the disease with evil actions or thoughts. Community members are fearful of catching the spirits or associ-ating with the “evil” person which can be emotional-ly devastating for Ebola victims.

Burials In many West African countries, when a per-son dies there are certain rituals that take place be-fore the burial. For example, in Liberia these rituals include laying hands on the deceased and washing the body. Mourners come to visit the body, some-times from very far distances, and family members work together to wrap the body and bury it (Epatko, 2014). This practice is healing and comforting to many West Africans but it also can be dangerous when Ebola is involved. The International Federa-tion of the Red Cross reports that the bodies of Eb-ola victims may be up to ten times more infectious than living Ebola patients, which has serious impli-cations for the spread of the disease (Roy-Macaulay, 2014). Safe burial practices for Ebola patients and traditional West African rituals are not always con-cordant, leading to increased feelings of grief and loss of control for family members of the deceased. Many West Africans originally objected to the new burial practices, which included spraying the body with disinfectant, keeping family members a safe distance away, and utilizing trained burial teams to

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carry out post-mortem cleaning and burial (CDC, 2014). However, after the integration of cultural compromises, such as allowing family members and religious leaders to attend funerals, there has been more compliance among West Africans (Epatko, 2014).

West African Society and Ebola Public Health Infrastructure Public health agencies across Western Africa have struggled in recent years with a lack of resourc-es, community distrust, and poor overall infrastruc-ture. It is well known that Africa has been faced with numerous public health issues for decades, includ-ing malaria, AIDS, and hunger. The international attention surrounding Ebola placed a spotlight on West African health care and exposed serious flaws in the public health system. Underfunding and un-derstaffing of medical centers across several nations are certainly part of the issue, which became evi-dent as hospitals saw more and more Ebola patients needing quarantines and high levels of care (Pizzi, 2014). Drug supply systems, healthcare manage-ment, the number of qualified healthcare workers, and lack of government subsidizing of health costs are other contributing factors to the overall weak-ness of the public health systems in West Africa (Kieny, Evans, Schmets, & Kadandale, 2014). As fear rippled through these countries, public health agencies struggled to quell panic and educate their citizens with accurate, up-to-date information. People across Liberia, Guinea, and Sierra Leone re-fused to leave their houses due to fear of exposure to Ebola or death. The few qualified healthcare workers in Ebola-stricken areas risked their lives to care for patients, often with insufficient supplies and unclear information on how to protect themselves (Kieny, Evans, Schmets, & Kadandale, 2014). Clearly, global involvement in the form of trained personnel and financial aid was essential to the outbreak control response as the public health agencies of the affected countries were not able to be effective at controlling Ebola on their own. Another public health concern is the dra-matic shift of already limited health care resources towards Ebola control. With so much attention being focused on providing care to Ebola patients, children in West Africa missed vaccines and fund-ing for more treatable or preventable diseases has been cut. In Liberia for example, a Catholic Relief

Services survey revealed that forty percent of missed childhood vaccines since May 2014 were directly related to the Ebola outbreak (Pizzi, 2014). Patients with other afflictions traveled far from home to seek care in order to avoid hospitals busy with Ebola patients. This overwhelmed hospitals in non-Ebola areas (Kieny, Evans, Schmets, & Kadandale, 2014). Overall, it is evident that the public health sys-tems of Sierra Leone, Liberia, and Guinea were not prepared for an epidemic of this magnitude. Poor public health infrastructure likely contributed to the extent of the outbreak and to increased health instability across the region.

Government Distrust Across Africa, a culture of government mis-trust is ubiquitous in everyday life. Nepotism and corruption are common in countries across Africa and constitutional rights are not always upheld (Leaf, 2014). When a crisis such as Ebola emerges and government intervention becomes necessary, gaining the support of the people can be difficult. Government actions in response to the Ebola out-break have, in some cases, deepened this mistrust and created more barriers between West African governments and their citizens. For example, in Monrovia, Liberia, a state of emergency declared by the government gave troops the authority to seal off a slum, effectively quarantining thousands of Liberia’s poorest from their families and livelihoods despite the fact that not every resident had been exposed to the Ebola virus (Leaf, 2014). Residents were upset about the quarantine, citing the govern-ment’s oppressiveness and perceived lack of empa-thy. The Liberians’ wariness of government agencies has led to issues in the fight against Ebola. Public health messages published by the Ministry of Health were not trusted by people in the community, lead-ing to a delay in infection control. Susan Shepler, a specialist on education and conflict in Sierra Leone and Liberia, explains communication amongst Libe-rians by writing, “In Liberia, people have historically used community information and rumors as a way of getting information at times when they weren’t sure whether to trust the government” (Thomas, 2014). Some Liberians even believed that the entire epidemic could be a hoax fabricated by the govern-ment to gain money from sympathetic groups and countries across the globe (Thomas, 2014). The dan-

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ger of relying on rumors is evident in a high-stakes situation such as the Ebola outbreak. Many West African citizens were filled with confusion and fear as they tried to decide which information was accu-rate and how to go about avoiding Ebola in the best way. Culturally ingrained distrust of the government undoubtedly influenced the spread of Ebola across West Africa and possibly exacerbated the size of the outbreak. In conclusion, the Ebola virus is a dangerous illness on its own, but when coupled with multiple cultural and societal factors in Western African, it was able to devastate a region. Time-honored beliefs intertwining spirituality, illness, and death under-mined the work of public health officials trying to educate the public on Ebola transmission. These beliefs also contributed to social isolation, fear, and stigmatization among the people of West Africa in the face of Ebola. Strained public health structures contributed to the spread of Ebola by failing to stop the outbreak at its very beginning. This failure can be attributed in part to an extreme shortage of qualified healthcare workers, medical supplies, and resources in West Africa. Widespread distrust of government officials, especially in Liberia, caused West Africans to question education on Ebola from the Ministry of Health and caused a delay in get-ting prevention measures in place across all three affected countries. While outbreaks of Ebola have occurred in the past, the magnitude of this epidemic compels the global health community to consider a better plan for the future. On the local level, en-gagement with community leaders to gain trust and compliance among residents is vital to the success of outbreak prevention and containment (Sun, Dennis, & Achenbach, 2014). Culturally competent care is especially significant in these high-stakes situations, as discussed earlier with the change in burial proto-cols following the Ebola outbreak. Finally, it is im-portant to recognize how underprepared many parts of the world are for another outbreak of this propor-tion. Continuous aid and money must be commit-ted to these areas to improve baseline public health infrastructure and allow for better prevention and surveillance practices (Sun, Dennis, & Achenbach, 2014). As of April 12, 2015, the number of new Ebola cases per week has dramatically decreased from the number of new cases per week in February of 2015 (WHO, 2015). While this is promising news

for the global health community, it must not lead to withdrawal of support for West Africa. Over the next few years, careful thought and action must be invested in primary prevention of another epidem-ic because infectious outbreaks are a global health burden for all.

ReferencesCenters for Disease Control and Prevention. (2014). Ebola virus disease: Treat-ment. Atlanta, GA.

Centers for Disease Control and Prevention. (2014). Ebola must go: Bury all dead bodies safely. Atlanta, GA.

Centers for Disease Control and Prevention. (2015). Outbreaks chronology: Ebola virus disease. Atlanta, GA.

Centers for Disease Control and Prevention. (2015). 2014 Ebola outbreak in West Africa: Case counts. Atlanta, GA.

Epatko, L. (2014, October 14). Bringing safer burial rituals to Ebola outbreak countries. PBS NewsHour: World. Retrieved from http://www.pbs.org/news-hour/updates/bringing-safer-burial-rituals-ebola-countries/

Hewlett, B. S., & Amola, R. P. (2003). Cultural contexts of Ebola in northern Uganda. Emerging infectious diseases, 9(10), 1242.

Hewlett, B., & Hewlett, B. (2007). Ebola, culture and politics: the anthropology of an emerging disease. Cengage Learning.

Kurtzman, L. (2014). Understanding Ebola. University of California San Francisco News. Retrieved from http://www.ucsf.edu/news/2014/10/120016/understanding-ebola

Leaf, A. (2014, October 14). Ebola spotlights Liberians’ distrust of their po-litical leaders. Al Jazeera. Retrieved from http://america.aljazeera.com/opin-ions/2014/10/liberia-ebola-ellenjohnsonsirleafunconstitutionalpowergrab.html

Marais, F., Minkler, M., Gibson, N., Mwau, B., Mehtar, S., Ogunsola, F., Banya, S. & Corburn, J. (2015). A community-engaged infection prevention and control approach to Ebola. Health promotion international.

Muyembe-Tamfum, J. J., Mulangu, S., Masumu, J., Kayembe, J. M., Kemp, A., & Paweska, J. T. (2012). Ebola virus outbreaks in Africa: past and present. Onderstepoort Journal of Veterinary Research, 79(2), 06-13.

Pizzi, M. (2014, September 16). Ebola outbreak exposes West Africa’s existing public health woes. Al Jazeera. Retrieved from http://america.aljazeera.com/articles/2014/9/16/ebola-impact-publichealth.html

Roy-Macaulay, C. (2014, December 21). Sierra Leone Urges Safe Burials to Stem Ebola. The New York Times. Retrieved from http://www.nytimes.com/aponline/2014/12/21/world/africa/ap-af-ebola-dangerous-burials.html?_r=0

Sun, L.H., Dennis, B., & Achenbach, J. (2014, December 28). Ebola’s lessons, painfully learned at great cost in dollars and human lives. The Washington Post. Retrieved from http://www.washingtonpost.com/national/health-sci-ence/ebolas-lessons-painfully-learned-at-great-cost-in-dollars-and-human-lives/2014/12/28/dcc8c50a-87c2-11e4-a702-fa31ff4ae98e_story.html

Thomas, K. (2014, September 3). Mistrust of government spurs Ebola spread. IRIN. Retrieved from http://www.irinnews.org/report/100568/mis-trust-of-government-spurs-ebola-spread

Vallenas, C. (2015). Ebola diaries: Changing health worker culture. World Health Organization. Retrieved from http://www.who.int/features/2015/ebo-la-diaries-vallenas/en/

World Health Organization. (2014). Personal protective equipment in the con-text of filovirus disease outbreak response. Geneva, Switzerland.

World Health Organization. (2015). Ebola Situation Report: 15 April 2015. Geneva, Switzerland.

t

SARAH VOISINE is a BSN candidate in the class of 2015 at the University of Pennsylvania School of Nursing. Her interests include pediatric nurs-ing and nursing education. She plans to become a pediatric primary care nurse practitioner.

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Guatemala: Midwifery and Women’s HealthJennifer Toth

What do brown sparkles, a fake beard, and a papaya have in common? During May 2014, they were all among the many props my NURS 545 class and I used to teach the “charlas” (talks) we had been planning all semester to groups of parents, students, nurses, and midwives in Santiago Atitlán, Guatemala.

The weeklong trip was the final part of a semester-long course about maternal and infant healthcare in Guatemala, led every spring by midwifery faculty Mamie Guidera

and Dawn Durain and accompanied this year by PNP faculty member Victoria Weill. Our group of 12 students, a mix of undergraduates and graduates, spent the week in Guatemala working with comodronas (traditional mid-wives) and staff from various health promo-tion agencies. Partnering with members of the community, we worked in clinics, went on

home visits with nurses, and focused a lot of our energy on teaching efforts. In sometimes-broken Spanish we did skits, played games, and used lots of props to teach about various topics. Brown sparkles represented the bacteria that cause diarrheal illness, spread from one person’s hands to the next. Fake beards helped teenage girls act out scenarios identifying different types of violence against women. A papaya served as a uterus model for demonstrating the changes that occur during the menstru-al cycle. With a rich Tz’utujil Mayan heritage, the culture in the town is a fascinating mix of traditional modern

influences. You can buy a plastic toy or a lace bra in the market from a woman

wearing hand-embroidered indigenous cloth-ing, right next to a stand selling produce. In some of the small one-room homes, a family’s only visible possessions are a wood-burn-

Toth (left) studied abroad in Guatemala in May 2014. The School of Nursing at Penn offers opportunities to study abroad in the summer in several other countries, such as Hong Kong, Thailand, and Botswana.

study abroad reflections

Some Penn Nursing students study abroad and learn about health care in other contexts. Here, students share their experiences.

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“We had the girls act out scenarios aboutviolence against women and then brainstorm ways to prevent or stop them. Their acting was so convincing that it was clear these scenarios were not foreign to them.”

ing stove and a TV. People have many traditional Mayan beliefs about disease, but expect an injection or pill whenever they go to the clinic. Even after a semester of preparations for the trip there were surprises everywhere. One of our main goals of the trip was to make our efforts sustainable so that their impact would continue after we left. To that end, most of our work was focused on teaching rather than providing direct patient care. One day, a group of our midwifery students was teaching a class about neonatal resuscitation to a group of comodronas. One of the comodronas remembered learning about this from the group of Penn students that had been there several years earlier. She immediately jumped

in, demonstrating the techniques and explaining them to the rest of the comodronas. Watching that, our group thought, “This is sustainability in action.” Another particularly rewarding experience for me was leading several classes for teenage girls at an organization called Estrella del Mar. Estralla offers an amazing program that provides education to teenage girls to help them stay in school and prepare them to be leaders in their community, a

role that women and girls don’t frequently have in this community. During our time with the girls there, we discussed topics like the menstrual cycle, contraception, and intimate partner violence. In one activity, we had the girls act out scenarios about violence against women and then brainstorm ways to prevent or stop them. Their acting was so con-vincing that it was clear these scenarios were not foreign to them. When we discussed strategies to combat violence against women in their communi-ty, they had many creative ideas that demonstrated a deep understanding of a complex issue and the many cultural factors at play in their culture. At the end of the day, the girls thanked us profusely, say-ing “thank you so much for teaching us about that,

nobody here knows or talks about that.” We felt less like we had been teaching them, though, and more like we had been working together. When people ask me about my experience in Guatemala, I’m not really sure where to start. Before the trip, I felt unprepared.

I thought my Spanish skills would be worse than everyone else in my class. I wasn’t sure that I had anything to contribute to our group’s efforts. Little did I know, other people thought the same thing, but none of us were actually right. Everyone brought different knowledge, skills, and experiences. Just as importantly, we all gained knowledge, skills, and ex-periences that will help us be better nurses wherever we ultimately work.

Students taught neonatal resuscitation to comodronas, traditional midwives in

Guatemala.

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England: Impressions of Nursing Hierarchiesin the United Kingdom Katelyn Ward

In my fall semester of junior year I had the pleasure of participating in the Penn Nursing Exchange Program in Oxford, En-gland. The program allowed me to experience a brief introduction to global health and an extension of my minor in healthcare manage-ment by exploring the National Health System (NHS) in England. Assimilating to a new cul-ture is a challenge in itself, but being an active caregiver in the healthcare field of this new culture when I have not yet established my place in healthcare in the US was its own feat. On the surface, much of the healthcare system in the UK appears similar to that in the US including equipment, procedures, and a hierarchy of healthcare pro-fessionals. It was only over the course of the 240 hours that I spent in the clinical setting that I was able to fully comprehend where the differ-ences lie and how this affects patient care and the overall attitude towards the system. I had briefly studied the NHS system in several of the classes that I have taken towards the healthcare management minor at Penn, focus-ing on why nationalized healthcare was im-plemented, as well as the benefits, the disad-vantages, and where it may lead in the future. However, I had not been able to experience first hand the attitudes of UK citizens towards the NHS and their opinion of the healthcare system in the US. The clinical experiences that I had were on a neurosciences ward in a major hospital in Oxford and with the health visiting team who visits the homes of new infants and mothers to preform development reviews. I

found the neuroscience experience to be very similar to acute care in the US. However, the health visiting team was unlike anything we have in the United States. The program is funded by the NHS and provides develop-mental reviews for infants at two weeks after birth, eight weeks, one year, and two years. The program is run by nurses and midwives and focuses on issues related to feeding, sleep-

ing, temperament, and parenting. This allowed problems to be ad-dressed and often revised without a visit to the primary care provid-er, saving time and money for all individuals. My first impression of nursing in the UK was that it is far more traditional than the US. Uni-forms consist of collared dresses that hang at mid shin, charge nurses are referred to as “Sisters”, and females make up nearly the entire workforce. Globally, nurs-ing has slowly progressed to be a

profession that extends beyond its traditionally conservative origins, but in England the progress ap-pears to come a bit slower. The low

government-paid salaries are not supportive of the very important role that nurses play in keeping patients safe and healthy. There is also limited opportunity for growth pay-wise, and tight restrictions by hospitals require addi-tional training in order to perform certain nursing duties that are considered basic nurs-ing skills in the US. In spite of these realities, nurses are often understaffed causing unsafe conditions for patients and a hectic work environment. When this understaffing causes a need for prioritizing, it is often the patients who are the most ill and require more care that are affected the most. Their inability to assert

Ward noticed a more traditional image of nursing in the UK of “collared dresses that hang at mid shin.”

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Australia: A Student’s Perspective on Education Experiences AbroadJane Chung

It has already been three months into my study abroad program here in Brisbane, Australia as a nursing exchange student studying at the Univer-sity of Queensland. While BSN programs back in the States are typically four years, the UQ nursing program here is only three years, but one of the best in the country. The program requires that we attend problem-based learning group and lectures at the Princess Alexandra Hospi-tal on a weekly basis, and that we complete 240 clin-ical hours over the course of the semester. Like at Penn, we discuss case study scenarios in learning groups, and instructors place a strong emphasis on evidence-based research. One thing I find really interesting is that indigenous and aboriginal health is a recurring topic

of discussion in both lecture and in learning group. Because of the existing health disparities between indigenous peoples and non-indigenous Australians, the program teaches students about cultural under-standing and how nurses can better deliver cultur-

ally appropriate care to this population in order to confront the health gap. Another thing I enjoy about the program is that it offers more hospital exposure than my clinical schedule would have been at Penn.

their needs like more healthy patients can leaves their care at a higher risk to be forgotten or not pre-formed at the appropriate time. Solving issues like these should be an easy fix and an excellent way to improve patient outcomes, but the government run system does not always focus on quality improve-ment or staff concerns. Another difference between UK nursing and US. nursing is a more complex ranking system of registered nurses in the UK. Different banding for nurses is used to designate nurses with more experience and additional qualifications to perform certain duties like administering IV drugs, inserting cannulas, and blood transfusions. This also provides a system for pay increments based on experience, which incentivizes nurses to seek a higher banding. These bands, as well as nurse managers and senior nurses, create quite a lot of authoritative figures on a ward, where jurisdiction between colleagues is

not always clear. These factors in combination can lead to disorganization and lower quality of care for patients. Attention to details like these is something that I have come to value in privatized hospitals in the US. where care is expected to run like a well-oiled machine. The care that I was able to give as only a junior year nursing student in Britain was far great-er than any care that I will be able to practice as a student in the US. There are fewer restrictions on students, allowing them to contribute more to the total workload, which is a necessary relief when the ward is understaffed. These learning opportunities as a student in Britain were amazing experiences that I would not have been able to achieve as a ju-nior year nursing student in the US, but nursing as a profession and institution is far more progressive in the US and allows many more opportunities in the long-run.

“Because of the existing health disparitiesbetween indigenous peoples and non-indigenous Australians, the program teaches students about cultural understanding and how nurses can better deliver culturally appropriate care to this population in order to confront the health gap.”

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I am doing third-year clinical at the Mater Public Hospital adult’s intensive care unit, where I work twelve hour shifts, both days and nights, usually two or three times a week. Having never been on an adult ICU unit be-fore, this was a very new arena. It was both daunting and exciting. Rather than working with a clinical instructor on the unit, I am paired up with one of the unit nurses who serves as my preceptor for the shift. I have been fortunate to have had several help-ful and kind preceptors who have served as positive mentors for me. This has forced me to break a little bit out of my shell and become more independent. Unlike at the Children’s Hospital of Philadelphia, where I had completed my last clinical experience before leaving for Australia, I am not required to spend time at the computer documenting. This is because our patient records and charts are on paper, not on electronic medical systems. It was initially surprising for me to see less of the fancy technology I was used to seeing at Philadelphia hospitals. Back at CHOP, it was typical that nurses were juggling three patients and would be in and out of the room. There would usually be several other employees such as respiratory therapists and technicians coming into to give certain medications, manage machines, change beds, and do certain ther-apies. However, here the nurse is the one constantly responsible for the entirety of the patient space. The

nurse gives all the medications, changes and bathes the patient, and monitors the patient and machines such as the ventilators. It is not uncommon that the nurses have only one patient for the day and are constantly at the bedside. The job entails doing thor-ough head-to-toe assessments, administering medi-cations, changing and bathing the patient, recording nursing observations on the hour, coordinating with other members of the team, and talking with both patients and families. Here I have been fortunate to practice many nursing skills. For example, I can now more confi-dently draw up medications, administer subcutane-ous injections, draw blood for ABG tests, hang IVs, do CPR, and bathe and dress patients. A majority of my patients are intubated, so I am also learning a lot about caring for a patient with an endotracheal tube. With already 96 hours under my belt, my experience so far has been quite a valuable one. With the amazing education Penn has provided me along with the practice I’m receiving here, I can honestly say I’m a lot less terrified about graduating in a little over a year. I am starting to see myself as less of a student and more of a nurse. I highly encourage any nursing students interested in studying in Australia to apply. It is an opportunity not only to learn more about nursing, but to learn about yourself and the world outside Philly.

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A Spanish Nursing Student’s Experiencein ScotlandJorge Riquelme, University of Alicante, Spain

Introducing the ERASMUS Programme The ERASMUS Programme is a well-known grant developed and funded all over Europe by the European Commission on Education. This grant allows students to develop part of their undergraduate studies in other European universities. The University of Alicante offers nursing students the opportu-nity to carry out the second period of nursing training in different countries such as the United Kingdom, Portugal, Italy and Finland. This report focuses on my ERASMUS experience and how I lived it two years ago, in my third year as a nursing undergraduate. (Spanish nursing undergraduate education consists of four academic years.) I applied to be hosted at Robert Gordon University in Aberdeen, Scotland, as I was interested in improving my English and in learning more about Scottish culture. According to Lee, “students believe that their internation-al experiences have a deep impact on their personal development, helping them make the transition from student to qualified nurse” (2007). In fact, European Mobility Programmes provide nursing students with valuable experiences and an improved under-standing of nursing in the global community. Those goals stated by Lee were the ones I had in mind when I applied for the program, and nowadays I also consider those were the main outcomes I gained after such a challenging experience.

The City of Aberdeen Aberdeen, known as the Granite City, is situated on the northeast coast of Scotland and has a population of about 200,000 inhab-itants. It is one of the most important petrol business areas in Europe. Aberdeen Royal Infirmary is the largest hospital in Europe, occupying over 13 buildings. Aberdeen has

the highest life standard in the UK. During my healthcare and clinical placement, my colleagues and I were hosted by an adjunct clinical professor and different hospital men-tors, depending on the clinical unit or service. They introduced us to the city of Aberdeen, the most common Scottish costumes and tra-ditions as well as the development of nursing cares in their professional culture.

Achieving Skills: Transition and Barriers Being treated as a British nursing student was one of the main outcomes of my experience. For that reason, I achieved prac-tical and technical skills and critical thinking regarding knowledge about adult care, and how it has been considered through nursing competences described by the British Na-tional Health System (Nursing & Midwifery Council, 2010). As I could observe, students’ feelings, associated with the transition from their countries to the host culture, were significant in the process of achieving in-tercultural competence and characterized their experience. During that transition, all students struggle with feelings of ignorance, frustration, anxiety and anger, according to Koskinen & Tossavainen (2004). Remember-ing now my first weeks, I can corroborate this idea. Exchange students have to handle language barriers, unknown contexts and habits, and usually, share living space with other English or non-English-speaking students. However, the worst feeling you can have as a nursing exchange student happens at the hospital. I belong to another culture, so these cultural and linguistic aspects became problems in a hospital daily routine. Scottish people talk to you as a professional or even as a native student. It takes them a few hours to be aware that your learning needs and

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level of understanding the language are different. Sometimes, mentors and colleagues do not have real time to attend a foreigner and workloads and labor pressure could be the cause. However, it made me reflect on my own way of acting with foreigners in my own country. As Edmonds (2010) says, the opportunity to be “out of your comfort zone” will create a memorable op-portunity to learn how to adapt and to recognize culture shock in your patients. Your point of view changes into a more professional one, becoming more independent and self-sufficient along your nursing practice. Being abroad for three months enabled me to compare different healthcare systems, not only based on a theoretical basis, but also on my personal experiences. According to Keogh, students studying abroad gained the ability to analyze and critically discuss different healthcare systems (2009).

The Scottish Healthcare System To reduce those difficult situations men-tioned before and to improving our skills, the host university planned for us a basic cardiopulmonary resuscitation (CPR) module and another one about patient mobility and functioning at the university skills labs. It was such a great opportunity to meet Scottish students and to be taught in different meth-ods, as for example, lab simulation. The lab recre-ated one local hospital room and it was very useful. After that, when we got into the real context, we realized that there was not any difference from our lab environment and our placement context. In my opinion, it increased our self-confidence due to the fact that we already knew where everything was. It really made the difference and made transition eas-ier. Mezirow states that learning always takes place within the context of problem-solving, and that critical reflection and self-reflection on the content, process and premises of the problematic situation are therefore the ways to change one’s mind (1994). After those university seminars, our adjunct clinical professor introduced us to Aberdeen Royal Infirmary, the mentor and the ward where we would be allocated. In my opinion, one remarkable fact was the “Students’ Book” that Scottish Universities use at clinical placements. In the wards where my clini-cal practice took place, my mentor gave me some papers about the most common diagnosis in that ward, typical drugs used, and also a routine guide.

It helped prepare me. When I came back to Spain, in the next placement I had at an intensive care unit in Clinica Vistahermosa Hospital, I proposed to the nurse manager to develop an ICU Students’ Book in order to help future students in their transition be-tween wards, units/services and so on. Months later, I pleasantly heard positive comments from students that received those papers before starting in the unit. At that point, I felt I could make the difference even in my own context!

Differences Between Healthcare Systems In my opinion, the first moments in a differ-ent healthcare context are crucial. Spanish nursing students are used to practice more on techniques during their clinical training than the British ones. However, UK nurses competences are restricted ac-cording to the rank or level. Students and registered nurses focus on holistic care tasks such as obser-vations, hygiene, diet, and comfort care. Some of these skills were new to me, such as patient hygiene or patient feeding and postural changes. Comparing both ways of working, UK nurses seemed stricter than Spanish ones in some issues such as medication checks. They do a double check of medication by themselves and with another colleague, especially regarding the dangerous med-ications like morphine or other strong pain killers. As a consequence of those good practices, I realized about the importance and how potentially risky our common tasks can be, how relevant it is to confirm the patient’s identification and birth date, dose to be administered, and drug expiration. In Spain, we also do all of these actions, but maybe, and of course, it is my own opinion, not as strictly as in the United Kingdom. I should say that those procedures have not been standardized nationwide as policies related to patient safety are starting now. All those differences could be attributed to the nurse-patient rates and work conditions. As Aik-en et al. stated in different studies, the rate of nurs-es per patient can affect the quality perceived and modify patient security (2014). “Hospitals in which nurses cared for fewer patients each and a higher proportion had bachelor’s degrees had significantly lower mortality than hospitals in which nurses cared for more patients and fewer had bachelor’s degrees” (Aiken et al., 2014). Spanish and Scottish healthcare systems

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have both public and private institutions. Howev-er, Spanish and British public systems provide free basic healthcare to those who contribute by some taxes and are residents; in the case of foreign citi-zens, they are supposed to be employed. Both public systems are managed by the national government. It means that Public Spanish National Healthcare System for example, as a group of public healthcare institutions is affected, as other public areas, by the Spanish economic crisis. Moreover, I saw some work condition disparities. Fore example, British hospitals work with higher nurse-patient ratios and with few-er nurse assistants compared to Spanish hospitals.

Perceived Quality and Outcomes Achieved As a student, one common pattern has been experienced and seen: the quality of mentoring, car-ing, or patient satisfaction depends directly on how overworked a nurse is. This idea agrees with Aiken et al., who report that “nurse leaders have at least 3 major options for improving nurse retention and patient outcomes: improving RN staffing, moving to a more educated nurse workforce, and improving the care environment. [...] hospitals with even some of the features of magnet hospitals (investments in staff development, quality management, frontline manager supervisory ability, and good relations with physicians) are associated with better nurse and patient outcomes” (2008). After my experience, I realized that my critical thinking has been improved. I gained an open-minded way of thinking. Lee believed that the confidence gained from overcoming the personal challenges of the international experience, appeared to help students adjust to the complex role of staff nurse (2004). Nowadays, in my work as a profes-sional registered nurse, I can recognize how that competence changed me as a person and as a profes-sional too. As a nurse, I got a wider patient view, not only based on techniques but also on clinical diag-nosis. As a person, it allowed me to understand bet-ter the British culture, being more independent and being capable to solve a wide range of new problems related to professional issues. As one of the most important goals achieved, intercultural comprehension and tolerance made me a more tolerant person and a more skillful nurse. In my hometown, Alicante, we receive lots of tourists every day, and that’s why I consider it important to

have an exchange experience to be able to under-stand other people who you are taking care of, hav-ing in mind their background, culture, and habits. According to Greatrex-White, “If one of the major aims of nurse higher education is the development of culturally competent practitioners, study abroad is deserving of far greater attention than is currently the case” (2008).

Intercultural Skills Different cultures have different ways of expressing their feelings or social needs. Compar-ing both the British and Spanish cultures, I can say that the Spanish culture as a Latin-influenced one is more family-based. For example, when one relative gets ill in Spain, all the family goes to the hospital to visit them. Spanish patients are usually never left alone. On the contrary, British culture works differ-ently. In Aberdeen, patients’ relatives phoned every morning to ask nurses about them and came to visit them from time to time, but never as often as fami-lies do in Spain. As a Spanish nursing student without any prior international experience, that situation could have led me to judge wrongly patient social sup-port in the UK. In Spain, social support is equally understood as family support, and that fact is hold by the family home care which is still present in Spain nowadays. Consequently, that cultural sit-uation affects the Spanish Healthcare System and its organization and structure itself. In Spain, it is not assumed that patients stay at hospital without a relative or family, and therefore, the problems may appear when nurses are unable to stay longer taking care of one patient. Obviously, that fact determines that more dependent patients will have a higher risk of falls and disorientation. Finally, I considered those three months as a great challenge to improve my criteria in nursing outcome evaluation and basic nursing cares in an intercultural environment. According to Koskinen & Tossavainen, “gaining intercultural competence in an international exchange programme in nursing consists of three ethno-categories: transition from one culture to another, adjustment to the difference and gaining intercultural sensitivity” (2004).

ConclusionTo sum up, people are moving increasingly across

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international and linguistic boundaries because of their work, but also as immigrants and refugees. Consistently, nurses should be able to provide culturally competent care for more diverse popula-tions and ethnic groups. Thanks to the experience described, I met amazing people in Scotland, and we shared wonderful experiences at clinical placements talking about daily situations and comparing health-care systems. I developed critical thinking and inter-cultural skills. Moreover, I was able to get involved in the host culture, travelling around Scotland and visiting the most famous places. In short, I believe I became more intuitive, learning to recognize and interpret non-verbal communication in a different culture. Although I experienced some discomfort at the beginning as a result of the language barrier, I learned and adapted to the new culture. After this great experience I can only recommend students to be brave and take the challenge and go out of “their comfort area,” meet new people, new cultures, new ways of thinking and always give themselves the chance to continue learning. It is a genuine experience that for sure will change your life.

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Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993.

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., ... & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830.

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Lee, N. J. (2004). The impact of international experience on student nurses’ personal and professional development. International Nursing Review, 51(2), 113-122.

Lee, R. L., Pang, S. M., Wong, T. K., & Chan, M. F. (2007). Evaluation of an innovative nursing exchange programme: health counselling skills and cultural awareness. Nurse Education Today, 27(8), 868-877.

Edmonds, M. L. (2010). The lived experience of nursing students who study abroad: A qualitative inquiry. Journal of Studies in International Education.

Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuck-ler, D., ... & McKee, M. (2013). Financial crisis, austerity, and health in Europe.The Lancet, 381(9874), 1323-1331.

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student mobility: Meeting student’s expectations or an expensive holiday?. Nurse Education Today, 29(1), 108-116.

Koskinen, L., & Tossavainen, K. (2004). Study abroad as a process of learning intercultural competence in nursing. International Journal of Nursing Practice,10(3), 111-120.

Mezirow, J. (1994). Understanding transformation theory. Adult Edu-cation Quarterly, 44(4), 222-44.

Nursing & Midwifary Council. (2010).Standards for competence for registered nurses. Retrieved from www.nmc-uk.org

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JORGE RIQUELME is an undergraduate student in nursing science at the University of Alicante (Spain). Jorge hopes to contribute to global health by connecting universities and companies from around the world.

FACULTY ADVISORKathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA

Class of 1965 25th Reunion Term Professor of Cardiovascular NursingAssociate Dean for Academic Programs

University of Pennsylvania School of Nursing

2014-2015 Executive BoardOrganization of Student Nursing Research

PRESIDENT

Sarah Voisine ‘15EDITOR-IN-CHIEF

Andre Rosario ‘16

TREASURER

Shannon McCarthy ‘16ADMINISTRATIVE COORDINATOR

Chloe Swanson ‘17

FACULTY EDITORIAL BOARDMonica Harmon, MSN, MPH, BSNBarbara Man Wall, PhD, RN, FAAN

ASSISTANT PAGE LAYOUT AND COPY EDITORSElena Carrigan ‘18, Kimberly Peng ‘17,

Katelyn Ward ‘16, Grace Wong ‘16

osnr.penn@gmail.comwww.nursing.upenn.edu/osnr