Preparing veterinarians for work in resource-poor settings

Thomas W. GrahamVeterinarians Without Borders, 1124 Pistachio Ct, Davis, CA 95618

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Joyce TurkBureau of Food Security, US Agency for International Development, 1300 Pennsylvania Ave NW, Washington, DC 20523

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John McDermottConsultative Group on International Agricultural Research, International Food Policy Research Institute, 2033 K St NW, No. 400, Washington, DC 20006

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Corrie BrownVeterinarians Without Borders, 1124 Pistachio Ct, Davis, CA 95618
Department of Pathology, College of Veterinary Medicine, University of Georgia, Athens, GA 30602

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Food and nutrition security is achieved when food is adequate (in terms of quantity, quality, safety, and sociocultural acceptability) to live a healthy and active life and is available for, accessible to, and satisfactorily used by all individuals at all times.1 Globally, animal health professionals have a key role in promoting food security and enhancing human well-being by keeping food-producing animals healthy. The importance of this task was highlighted recently in a commentary2 published in the JAVMA in which the authors clearly articulated global needs to ensure food security and the importance of including animal health specialists in policy decisions. As opportunities for the profession to contribute in this arena increase, it is incumbent on veterinarians to ensure they are well prepared. However, much of the education and experiences veterinarians receive in the developed world may be less useful in resource-poor settings, and veterinarians who intend to work in these settings need to ensure they are prepared to contribute. The purpose of this paper is to clarify key issues that must be understood for veterinarians to work successfully in resource-poor settings.

Three concepts are key to successful project development and delivery in resource-poor settings, regardless of the institution or nation where participating veterinarians were trained. First, it must be understood that in these settings, food animals are the focus at the household level because they are part of the microeconomy and central to food security—livestock are lifestock. Second, the role of the host country's NAHS must be recognized because all animal health care takes place within this framework and failure to recognize this framework could easily result in inefficient efforts or negative outcomes. Third, intercultural awareness and attention to cross-cultural communication must be made a priority because doing so is absolutely central to ensuring that efforts are worthwhile, positive, and sustainable.

Livestock are Lifestock

In the past 50 years, global development efforts have largely focused on crop production, almost to the exclusion of animal production. More recently, recognition of the need for ASF production has increased to the point that livestock are considered key to sustainable food production and are understood to be important to ensuring food security, expanding small-holder incomes, and growing national economies.3–6 As a result, many donor agencies such as the Food and Agriculture Organization of the United Nations, the World Bank, the US Agency for International Development, and the European Union now promote and finance livestock projects to improve the microeconomy, support human nutrition, and enhance marketing opportunities for the benefit of the national economy.

Livestock expand and support the microeconomy—Approximately 1.2 billion people in the world are classified as extremely poor, living on < $1.25 a day.7 Most of these extremely poor individuals live in rural areas and depend on subsistence agriculture. It is estimated that 90% of the world's extremely poor are small-scale farmers, and livestock in small-holder settings provide important economic, sociocultural, environmental, and nutritional value. Economically, livestock represent savings, income, decreased vulnerability to unforeseen negative events, and increased resilience.8 The household economic return on livestock production is approximately 10%, making these animals a good investment and a potential path out of poverty.4 Also, often it is women who are responsible for caring for household livestock, and proceeds from the sale of chickens, eggs, or small ruminants are invested into the family support structure in the form of school fees or health care, which improves overall human capacity and development.4,5,9

Importantly for veterinarians working in resource-poor settings, these small-holder settings bear little resemblance to situations in the developed world. Often, animal feed is the most important factor limiting capacity. Therefore, a good grasp of animal nutritional requirements and feedstuffs would be useful for veterinarians from developed countries who are preparing to work in these settings. Additionally, a rudimentary understanding of land and water laws in the country will help immensely, especially if working with pastoral groups or groups with clan systems of ownership.

Livestock support human health and nutrition—Biologically, livestock provide valuable nutrients, fuel, traction, transport, and nutrient cycling.4,10 Livestock products (ASFs) have increasingly been recognized as critical for improving human health and nutrition in many areas of the world. The United Nations Food and Agriculture Organization estimates that globally, approximately 870 million humans were chronically undernourished between 2010 and 2012 owing to low consumption of dietary energy.3 But this does not address the true nature of inadequate nutrition. The diet of the poor is largely cereal-based, and although it may contain sufficient protein and calories for sustenance, it often does not have the proper balance of amino acids and is lacking critical micronutrients. Approximately 2 billion people in the world suffer from micronutrient deficiencies, including deficiencies of iron, zinc, vitamin A, vitamin B12, and folate. Almost half of all children and pregnant women in the developing world have iron-deficiency anemia.11,12 Because children have higher requirements for micronutrients than adults do, on a body mass basis, these deficiencies are more prominent in the early years and have permanent negative impacts on physical and cognitive functions.13 Not only are all of these micronutrients contained in adequate quantities in ASFs, they are also more bioavailable than are nutrients found in plant crops.14 Consequently, promoting small livestock production (poultry, fish, and small ruminants) will help to permanently expand human capacity by supplying key micronutrients. Understanding these micronutrients and which ASFs are available in a particular setting could drive the most nutritionally beneficial animal production strategies.

The value chain of livestock production and marketing is fragile—Improvement in a regional economy is dependent on enterprises that are part of income generation. All segments of a particular enterprise interacting together are termed the value chain, which implies integration from production and harvesting of raw resources to processing and selling of finished products at the retail level. In the case of livestock, the value chain refers to the so-called farm-to-fork sequence. In North America, the livestock value chain is fully developed and functions so well as to be almost invisible to most veterinarians and consumers. In contrast, the livestock value chain is typically nascent in the developing world.

There are multiple levels in developing livestock value chains, including breeding and growing young stock, finishing mature animals, processing and selling food products, providing quality assurance, marketing finished products, and meeting consumer preferences and demand. Each link along this value chain is vulnerable and must be supported to ensure the system maintains economic viability.15 In the developing world, the value chain is often inconsistent or fragile. Importantly, improvement in one part of the value chain does not necessarily translate into an overall increase in capacity or an improvement in economic or human health.8 For instance, building chicken houses to grow large numbers of broilers may not result in enhanced income if there are not sufficient processing plants, consumers are wary of purchasing refrigerated products, or individuals are too poor to afford the product. Simply improving one part of the value chain may not result in overall growth of the commodity market or enhance the economy, food security, or nutritional security. Consequently, US veterinarians working in the developing world need to recognize that improvements have to be approached in an integrated manner and need to focus on policies and projects that will result in sustained growth and resource change.

National Health Monitoring System

In all countries, ensuring animal health is a private-public partnership, with the degree of contribution from each side of that partnership varying from one country to the next. Three main groups comprise the NAHS in every country of the world: policy makers, health service workers in the field, and diagnostic and testing laboratories. Their efforts support disease surveillance activities, which provide information on the national disease situation and allow for effective use of resources in control programs.

National animal health systems differ between developed and developing countries. In general, the NAHS in most developed countries has a large field force of health service workers, most of whom are private veterinarians accredited by the government to engage in various activities in support of the NAHS. This large field force, in conjunction with a network of public and private diagnostic laboratories, supplies the necessary support for passive and active surveillance activities under the direction of policy makers working in collaboration with industry partners. By contrast, the NAHS field force workers in most developing countries are typically public employees who are often poorly funded and have insufficient access to diagnostic laboratories or inadequate means of submitting samples for testing.

Working successfully in a developing country requires understanding the dynamics and constraints of the NAHS, which may differ markedly from those associated with NAHSs in more developed countries. As an example, there are several initiatives to foster inter-agency cooperation in East Africa, both within nations and regionally. However, each national health ministry traditionally functions independently. To facilitate ASF production, measures for disease control, standards of medical and veterinary practice, drug distribution systems, food safety protocols, and quality control procedures for human and veterinary drugs need to be in place. In the United States, this involves various portions of the USDA, Department of Health and Human Services, Department of State, Department of Commerce, Department of Education, Department of Justice, and Department of Homeland Security all acting in concert and with their counterparts in other countries.

Policy makers—Every national government has a veterinary services division that employs animal health specialists who monitor for and strive to control diseases of animals that affect the public good. These public good diseases are those that have a social and economic impact beyond the individual producer or owner. As such, they include zoonotic diseases, such as rabies, tuberculosis, and brucellosis, and diseases classified as transboundary diseases. The international community classifies transboundary animal diseases as “those epidemic diseases which are highly contagious or transmissible and have the potential for very rapid spread, irrespective of national borders, causing serious socio-economic…consequences.”16 Examples of transboundary animal diseases include foot-and-mouth disease, highly pathogenic avian influenza, and peste des petits ruminants.

The chief veterinary officer serves as the official leader for animal health activities within a country. The chief veterinary officer is a government employee who manages all efforts related to public good diseases for the nation, serves as the face of the NAHS to the rest of the world, and represents the nation in the World Organization for Animal Health (OIE). The chief veterinary officer helps form policy, often in partnership with key industry stakeholders. These industry partners, representing the private sector, may also participate in surveillance and control programs. Most veterinarians in the United States are likely unaware of the key regulatory veterinarians responsible for maintaining control programs related to public good diseases, despite the fact that veterinarians in private practice play a key role in surveillance activities related to reportable diseases. These reportable diseases represent the public good diseases that the US NAHS strives to monitor for and control.

In resource-poor nations, the private sector is usually minimally engaged in NAHS functions. Because most animal health monitoring and control programs in the developing world are in the public sector, it is incumbent on veterinarians entering a developing nation to begin with the public sector. The first stop in-country should be with the chief veterinary officer or his or her representative. Failure to connect with the NAHS could easily result in misplaced efforts or even ill will.

Often, the NAHS in developing countries has inadequate information on diseases present in the country. National control programs may, therefore, be lacking or insufficient. Often, control programs that do exist are funded by donors and based on specific or perceived needs of the donor agencies.10 Two examples of large donor-funded projects in the recent past include the rinderpest eradication campaign and the highly pathogenic avian influenza (H5N1) control program. The rinderpest eradication campaign was well coordinated internationally, with multiple donors and defined end points.17 In contrast, the highly pathogenic avian influenza control program was fragmented, with multiple governments and agencies engaged. The H5N1 avian influenza virus continues to circulate, albeit at a much reduced level. In the absence of rigorous, end point–oriented programs, donor-funded efforts at controlling this organism have proven to be unsustainable. Ensuring that any donor-funded disease control program is in line with the country's overall needs will help to ensure sustainability. Also, working in partnership with existing donor programs in the country can enhance efforts and provide synergy.

Field force workers—Globally, field workers in animal health are those who work at the farm level. They are the eyes and ears for disease recognition. In the United States, this includes a large number of private veterinarians who are integrated seamlessly into the NAHS through the process of USDA accreditation. These private veterinarians supply the necessary support for preliminary surveillance for public good diseases and allow government systems to operate efficiently in an almost invisible manner. In contrast, in developing nations, the ratio of public to private veterinarians is often the inverse of what is present in North America or Europe. That is, most veterinarians working in most resource-poor countries are public employees. Often, they are few in number, have limited expertise, and are minimally able or unable to deliver needed services.

Most developing nations are emerging or have emerged from authoritarian or colonial regimes in which all services, including animal health, were provided by the government. The policy of the World Bank and other multinational financial service organizations has been that public sector services in developing countries should be privatized, a reform known as structural adjustment. Although these structural adjustment programs have been largely successful from a macroeconomic perspective, many less prominent public sectors, such as the animal health sector, were unable to quickly privatize, and there was a general collapse of animal health infrastructures.18 The model of fee-for-service veterinary practice is quite new in the developing world and not totally accepted, available, or affordable by producers who in the past were able to obtain diagnostic testing and veterinary treatment free of charge. Creating a sustainable system will require the private sector to enlarge and develop a quality fee-for-service system in compliance with national governmental standards and regulations.

In developing countries, supporting the capacity of the few private livestock veterinarians who do exist to earn income is absolutely essential. Although it may seem generous or altruistic and even intuitive to provide free veterinary care to poor farmers, donor organizations that do this may undermine the sustainability of the private sector and ultimately the sustainability of animal health in the country overall.

Diagnostic and testing laboratories—There is marked variation in animal health laboratory capacity throughout the world. In some countries, these laboratories are staffed by capable veterinarians, microbiologists, and laboratory technicians who consider full lists of differential disease diagnoses and analyze samples with appropriate tests to determine the problem in the field. However, this is rarely the case in the developing world. In most resource-poor countries, animal health diagnostic laboratories function only with limited testing abilities and may not have reliable sources of water, electricity, or refrigeration. They may lack the capacity to perform simple diagnostic procedures such as bacterial culturing or agar gel immunodiffusion, but may possess PCR assay machines purchased as part of a donor-sponsored program to diagnose key high-consequence pathogens, which are often of more interest to the donor nation than to the host nation. However, without continuing technical support or a ready supply of reagents and because of erratic access to electricity, these machines are often not being used. Sophisticated technology for diagnostic testing, although highly valued in developed countries, usually proves unsustainable when transferred to developing countries. Rather than implementing procedurally complicated or expensive diagnostic testing methods, building human capacity to do basic testing and consider the full range of diagnostic possibilities through enhanced critical thinking may be the most valid and sustainable laboratory contribution. For instance, training laboratory workers to read impression smears or develop fluorescent antibody tests would be more sustainable than implementing molecular techniques in many resource-poor settings.

In all countries, laboratory specialists, in tandem with policy makers, monitor the efficacy and quality of veterinary drugs and biologics. Unfortunately, such capacity often does not exist in the developing world and counterfeit medicines have, as a result, found a huge market in resource-poor settings. Global sales of counterfeit medicines is estimated to exceed $75 billion and grew by 90% between 2005 and 2010.19 This surge in counterfeit medicines compromises animal health by degrading consumer confidence in veterinary drugs as well as in the veterinarians prescribing those drugs. Current efforts by international task forces are aiming to stem the trade in counterfeit medicines. It has been estimated that the value of counterfeit veterinary drug sales in Africa is equal to the value of legitimate drug sales, at $400 million.20 This means that as much as 50% of all veterinary drugs sales in Africa involve counterfeit formulations that may not be efficacious or safe.

For drugs and biologics that must be refrigerated, maintaining an appropriate storage environment in areas with transport or electrical supply issues can be problematic. Consequently, such drugs may lose efficacy or be used beyond their expiration date. Such problems compound animal health control efforts and must be taken into consideration when working in a resource-poor setting. Veterinarians must consider these factors when they prescribe, deliver, or recommend treatments.

Surveillance—Surveillance is the core activity of an NAHS and has two forms: passive and active. In the United States, passive surveillance predominates as diseases in the field are diagnosed and reported. Some active surveillance for key public good diseases, such as tuberculosis and brucellosis, also occurs regularly, especially through sampling at slaughter facilities. All of this surveillance serves to inform the NAHS on major animal health issues and trends. In the developing world, passive surveillance is infrequent and most surveillance is active, with government programs seeking to define the range and extent of specific diseases. However, this system is often ineffective in determining the true range and importance of all diseases. Encouraging increased capacity for passive surveillance would greatly enhance the NAHS. Veterinarians wishing to work in a resource-poor setting could contribute by building capacity for passive surveillance. Recognition of clinical signs and lesions for syndromic surveillance, consideration of a full list of differential diagnoses, and developing methods for sample collection are all areas for growth. Teaching these skills could have considerable sustainable impacts.

Educational systems—Processes for accrediting veterinary educational institutions and licensing veterinarians differ widely from country to country, resulting in dramatic differences in the numbers of veterinarians and their quality of training. Outside the developed world, there is an almost total absence of professional oversight of the accreditation of veterinary educational institutions. This has allowed for a proliferation of schools offering a veterinary diploma, even though many of these schools lack practical training courses. Some countries have so many veterinary schools that there is a tremendous over-supply of veterinarians in the workforce. For example, the Commonwealth of Independent States (a regional organization whose participating countries are former Soviet Republics) and Brazil have > 50 higher educational institutions that grant degrees in veterinary medicine.21 The Philippines has 16 veterinary degree–granting institutions, Mexico has 32, and Italy has 12.21 Consequently, some nations have tremendous underemployment of veterinarians. Also, many veterinary educational institutions do not include practical training courses, so veterinarians may graduate without ever having performed a surgical procedure or, in some cases, even conducted a clinical examination. When working in a resource-poor setting, it is useful to remember that veterinary education differs dramatically around the world and that what might seem to be basic knowledge in the developed world may prove to be a novel concept elsewhere. In addition, it is also important to recognize the role and expertise of community animal health workers, who often work as substitutes for veterinarians. Often, these community animal health workers receive training through certification programs that encompass three months of training and are focused on fee-for-service vaccination and antimicrobial or anthelmintic treatment, without diagnostic validation of the cause of illness. In localities where no other animal health services are available, these community animal health workers are much needed to fill a void. But inappropriate antimicrobial or anthelmintic treatment may lead to resistance, and without appropriate veterinary oversight, diseases and resistance may proliferate.

Cultural Awareness

Intercultural competence is the “ability to communicate effectively and appropriately with people of other cultures.”22 Here the key words are effectively and appropriately. Appropriate communication involves the surface, or explicit, aspects of culture (all those aspects of cultures that we see and hear, such as language, music, dress, and gestures). Anyone who has traveled overseas may be familiar with incidents involving minor cultural gaffes that occurred as a result of behaviors considered inappropriate in the host culture. Effective communication involves the implicit parts of culture, which are much more difficult to appreciate because they represent values and thought patterns programmed from childhood. These values and thought patterns form the underpinnings and beliefs that constitute a cultural mindset. We cannot see or hear these aspects of culture, but they are hardwired into our behaviors and judgments. National cultures, which have been referred to as “software of the mind,” can and usually do differ dramatically.23 As a computer analogy, software programs that work on an Apple platform cannot be expected to work on a PC platform. Knowing that these systems are different and knowing how they are different can allow one to apply a software patch to achieve compatibility. A similar notional patch for cultural programming will help veterinarians work effectively within an unfamiliar cultural mindset. Basically, understanding interactions across cultures involves knowing one's own cultural values as well as the cultural values of the host nation. As an example, one of the main parameters of a national cultural mindset is the power distance index, the extent to which authority is regarded as important and unquestionable.23 The US national culture has one of the lowest ratings for this parameter, which means we have minimal hierarchical structures and genuinely value contributions from all levels of an organization. However, in a culture with a high power distance index, encouraging initiative or negotiating with an employee who is not at the top of a company hierarchy may be fruitless and might even jeopardize that employee's position. Similarly, with regard to individualism versus collectivism, the United States scores toward the individualism end of the scale, and a core part of American culture is that individuals strive for their own success and expect to be recognized for their accomplishments. However, in a culture in which collectivism is much more emphasized, singling out a member of a community or a class for special recognition could be embarrassing or even socially compromising for that person. Awareness of some of these key distinctions in culturally based motivations and behaviors could be instrumental in ensuring success.

Two other key aspects of cultural awareness are empathy and introspection. Empathy will allow for moving beyond the cognitive components of understanding a nation's culture and into true engagement.24 Introspection is essential because knowing the basis of one's own thoughts and behaviors will facilitate effectively bridging the gap that exists when dealing with individuals of different cultures. Reflective journaling, which is essentially writing to learn about one's thoughts, has been suggested as a method to enhance introspection and improve intercultural competence.25,26 These positive behavior patterns enhance intercultural communication and sociocultural relationships.

Partnering and Sustainability

When commencing work in a developing country, it is highly likely that there will already be other donors and groups in the area. All developing countries have existing programs funded by international donors. In 2010, an estimated 45 countries and 21 multilateral organizations provided overseas development assistance to 150 countries27; the United States participated in 139 countries through numerous governmental agencies and nongovernmental organizations. Private sector companies and foundations also operate multiple programs in developing countries. Partnering with existing programs enables synergy, allows donor aid to be used most effectively, and enhances sustainability. Establishing cooperation, coordination, and collaboration is a complex process, with potential pitfalls.28 But the ultimate results of collaboration, which are interdependence and consensus, create a sustainable system that, in the case of animal health development, provides a huge impact. So, in addition to ensuring that there are solid connections with the host country's NAHS, working with existing US governmental and nongovernmental organizations in a collaborative manner is highly desirable.

Conclusion

Food and nutrition security and veterinary medicine are closely aligned. Veterinarians have numerous opportunities to contribute to improving the lives of people in the developing world. With some intentional preparations and sufficient reflection, veterinarians can contribute in resource-poor settings to improve the health of animals and the welfare of their owners.

ABBREVIATION

ASF

Animal-source food

NAHS

National animal health system

References

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Contributor Notes

Presented in part at the 149th Annual Convention of the American Veterinary Medical Association, San Diego, August 2012.

The authors thank Jessica Kania and Alexandra Baker for technical assistance.

For all commentaries, views expressed are those of the authors and do not necessarily reflect the official policy of the AVMA.

Address correspondence to Dr. Graham (tgraham@dcn.org).
  • 1. Food and Agriculture Organization of the United Nations. Coming to terms with terminology. Committee on World Food Security. Available at: www.fao.org/docrep/meeting/026/MD776E.pdf. Accessed Jul 28, 2013.

    • Search Google Scholar
    • Export Citation
  • 2. Kelly AM, Ferguson JD & Galligan DT, et al. One health, food security, and veterinary medicine. J Am Vet Med Assoc 2013; 242: 739743.

  • 3. Otte J, Costales A & Dijkman J, et al. Livestock sector development for poverty reduction: an economic and policy perspective—livestock's many virtues. Rome: Food and Agriculture Organization of the United Nations, 2012;161.

    • Search Google Scholar
    • Export Citation
  • 4. Perry B, Grace D. The impacts of livestock diseases and their control on growth and development processes that are pro-poor. Philos Trans R Soc Lond B Biol Sci 2009; 364: 26432655.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5. Smith J, Sones K & Grace D, et al. Beyond milk, meat and eggs: role of livestock in food and nutrition security. Anim Front 2013; 3: 613.

  • 6. Thornton PK. Livestock production: recent trends, future prospects. Philos Trans R Soc Lond B Biol Sci 2010; 365: 28532867.

  • 7. World Bank. Poverty reduction and equity. Available at: web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTPA/0,contentMDK:20040961∼menuPK:435040∼pagePK:148956∼piPK:216618∼theSitePK:430367∼isCURL:Y,00.html. Accessed May 17, 2013.

    • Search Google Scholar
    • Export Citation
  • 8. Dangour AD, Green R & Hasler B, et al. Linking agriculture and health in low- and middle-income countries: an interdisciplinary research agenda. Proc Nutr Soc 2012; 71: 222228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Staal S, Poole J & Baltenweck I, et al. Targeting strategic investment in livestock development as a vehicle for improving rural livelihoods. International Livestock Research Institute. Knowledge Generation Project Report, Report to the Bill and Melinda Gates Foundation. Nairobi, Kenya: International Livestock Research Institute, 2009.

    • Search Google Scholar
    • Export Citation
  • 10. Forman S, Planté C & Murray G, et al. Position paper: improving governance for effective veterinary services in developing countries—a priority for donor funding. Rev Sci Tech 2012; 31: 647660.

    • Search Google Scholar
    • Export Citation
  • 11. Burchi F, Fanzo J, Frison E. The role of food and nutrition system approaches in tackling hidden hunger. Int J Environ Res Public Health 2011; 8: 358373.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12. Demment MW, Young MM, Sensenig RL. Providing micronutrients through food-based solutions: a key to human and national development. J Nutr 2003; 133 (suppl 2):3879S3885S.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13. Muller O, Krawinkel M. Review: malnutrition and health in developing countries. Can Med Assoc J 2005; 173: 279286.

  • 14. Allen LH. To what extent can food-based approaches improve micronutrient status? Asia Pac J Clin Nutr 2008; 17 (suppl 1): 103105.

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