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Should U.S. Academic Health Centers Play a Leadership Role in Global Health Initiatives? Observations from Three Years in China

Kolars, Joseph C. MD

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Author Information

When this article was written, Dr. Kolars was associate professor of medicine, University of Michigan Medical School, Ann Arbor. He is now associate professor of medicine, Mayo Medical School, Rochester, Minnesota.

Correspondence and requests for reprints should be addressed to Dr. Kolars, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905; telephone: (507) 284-2175; fax: (507) 284-5486; e-mail: <kolars.joseph@mayo.edu>.

The author gratefully acknowledges his friends and associates in China, from whom he learned much that is reflected in this article. He also acknowledges the important guidance and assistance of Dr. Jim Woolliscroft in the preparation of the manuscript.

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Abstract

Based on his work in Shanghai, China, the author believes that U.S. academic health centers (AHCs) should take a leadership role in global health initiatives. While acknowledging that most AHCs already have focused projects involving research or education with foreign institutions, he proposes a greater coordination of these projects into programs that, in some areas, could also be linked to clinical delivery systems where care may be provided. These AHC “platforms” overseas would be structured as a partnership between an AHC in the United States and one in the foreign country where the platform is located, to promote their missions of education, research, and service.

For example, U.S. AHCs benefit, and are often dependent upon, international trainees who seek further clinical or research training in the United States. However, the identification of suitable candidates and career guidance, so the students' career choices could benefit their home countries, are often lacking. Thus, the United States is often viewed as facilitating a “brain drain” of future leaders in academic medicine from developing areas of the world. The author proposes a way to lessen this problem by shifting more on-site training to settings in the students' home countries, which could occur if AHCs were willing to develop overseas platforms. U.S. students would also benefit from access to medical training in foreign lands for both the cultural perspectives they offer and the unique diseases and medical situations encountered. He also suggests that shared platforms would lead to greater research opportunities for institutions in the United States and abroad.

He argues for increased efforts at coordinating these activities with the rising demand for Western clinical services by multinational companies and U.S. expatriate communities overseas. The potential pitfalls of such initiatives as well as the need for permanent relationships are discussed. In conclusion, he believes that AHCs have an opportunity to establish global health initiatives through education, research, and patient care that will both enhance their own institutions and benefit the international community.

These are introspective times for U.S. academic health centers. Market forces combine with decreasing resources for education to undermine the core values of the enterprise. Meanwhile, many industries see their future strength to be in the international marketplace. As part of this trend toward globalization, academic health centers in the United States have an opportunity, if not an obligation, to play strategic leadership roles in global health initiatives, especially in the developing world. In this article, I explain and make a case for this view.

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BACKGROUND

In 1996 I took academic leave from the University of Michigan to join the faculty of the Shanghai Second Medical School. As the first foreign physician licensed in this region of China in over 30 years, I was asked by a consortium of leaders within the Chinese health system with financial support from outside investors to establish the first Western-style health care delivery system in Shanghai, the economic engine of China. Chinese officials were willing to take a risk on a new kind of venture that would be modeled after academic health centers in the West. The goal would be two-fold. First would be the creation of a health care system to serve the growing international community in Shanghai. Although accessible to all, the Chinese health care system in Shanghai (see Table 1) was not viewed favorably by many expatriates and travelers from the West.

Table 1
Table 1
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A second goal was to establish an infrastructure where education and academic exchange could take place between Western medical schools and the Chinese academic health care system. As in the West, it was hoped that the clinical revenue would cover costs and support the academic components of the project.

As planned, I returned to the United States in June 1999. Through the coordinated efforts of many in Shanghai and the United States, a successful multi-clinic health care system was in place and profitable.1 Students, residents, and junior faculty rotated with us from academic centers in the United States. We also had occasional learners from the Chinese medical system rotating through these clinics. We would occasionally be asked to participate in teaching rounds in the two leading university hospitals in Shanghai. However, as recently witnessed in the West, the success of our clinics was undermining the academic goals originally envisioned. When I departed, it was becoming clear that the revenue stream from our clinics was of greater interest to the local leadership than were the academic components. Furthermore, it appeared that the introduction of “another choice” into the deeply established state-controlled system could set in motion a number of problems for the local leadership. It was not originally envisioned that there would be a significant number of Chinese nationals as patients. However, over 25% of our patient base was from the local Chinese community. Despite a fee schedule 50–70-fold more than that charged in local hospitals,* these local patients perceived in us a value that was worth the price. The possibility of Western providers' suddenly attracting patients from the local community was worrisome to some within the Chinese leadership. Furthermore, time spent teaching and participating in other academic ventures took physicians away from revenue-generating activities. My attempts to recreate some of the “good” components of Western academic medicine were also being contaminated with the bad.

What are the “teaching points” from this three-year case study? I believe the opportunities for partnerships between U.S. academic health centers and communities in less developed areas of the world are enormous and can greatly enhance U.S. centers' missions of education, service, and research. I will draw from my observations in China to illustrate what I believe are worthy pursuits for academic and patient care partnerships in foreign settings.

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EDUCATION

At present, 123 medical schools in China have 263,000 students enrolled in their standard five-year curriculums. From my observation, enthusiastic learners are at least as common as in the West, and most would welcome the chance for further overseas study. In the United States, many of us have become most familiar with foreign trainees when they are enrolled in postgraduate clinical residency programs. For example, in 1998, 30% of the first-year positions offered through the National Residency Match Program were filled by graduates of foreign medical schools.3 A number of clinical training programs in the United States would not survive if the pool of international medical graduates was not available to draw from. On the surface, this seems like a successful, symbiotic relationship for the American academic medical establishment: training bright professionals from countries that will benefit upon their return home, while U.S. hospitals obtain the low-cost service that residents provide to academic health systems.

However, the benefits of this relationship are often limited, at best. While I was program director for the internal medicine residency program at the University of Michigan, I would receive three to four applications to the training program from international medical graduates, with a large contingent from China, for every application from a U.S. graduate. With the large variance in training and evaluation, it was difficult to distinguish the top applicants in this pool from those not destined to thrive. As such, it was rarely worth the risk of courting such candidates, particularly with an abundance of good applicants from U.S. schools. Furthermore, a common sentiment among many policymakers was that most international applicants simply wanted to leave their home countries, professing every intention of returning home after their training but in the end choosing to stay permanently in the United States. This created the impression of deception by foreign trainees in pursuit of more attractive lifestyles that were not available to them in their home countries. For example, in China, established physicians at top hospitals were paid on average $800–1,200/year, with top salaries of $2,400/year found among senior physician in leadership positions at prestigious hospitals in Beijing.2 This level of compensation represents less than 5% of the starting salaries for most foreign trainees during their clinical residency years in the United States.

It is true that the majority of trainees who pursue educational opportunities in teaching hospitals try to remain over the long term in the United States, draining the developing world of much-needed bright and talented professionals. Why is this “brain drain” from so many struggling communities taking place? I don't believe that most foreign trainees are motivated by the lifestyle and lucrative possibilities of the United States. In my experience, most applicants, at least initially, have every intention of returning to their home countries after training. However, I don't believe our education system facilitates this return, for the following reasons.

Meaningful clinical training in the United States, for the most part, requires foreign physicians to completely adjust to our system, involving a complex process of acculturation and practical patient care experiences that entail a commitment of three to five years. During this time a great deal of adaptation to an American way of life takes place. Undoubtedly, many eventually opt for the comforts and freedoms not commonly enjoyed in their home settings. However, I believe the chief reason trainees do not return is the lack of opportunity to practice the kind of medicine they've learned from their time in the United States. We have provided them with clinical frameworks that give professional satisfaction but cannot be pursued in their home countries. Those returning from study abroad often find very limited opportunities, and the infrastructures to capitalize on their training are usually missing. In short, we train them to no longer fit in at home.

In the United States, I have encountered many Chinese nationals in pursuit of clinical training. While working in the medical schools of Shanghai, I found very few physicians who had received such clinical training in the West. I did encounter many who had received research training and who, by virtue of their overseas experience, had been put into leadership clinical positions. They were typically the unchallenged authors of care standards with which they may have had little or no experience during their time overseas. I also encountered in China many frustrated academics who had witnessed their best and brightest students leaving to study in the West and realized that they probably would not return. Understandably, these academics view with skepticism any proposed partnerships that they see as further depleting their most valued human resources.

Academic medical centers in the United States should take a leadership role in changing this pattern. A formal, dynamic partnership between medical centers of the East and West could establish programs where more training could be achieved in the home country with a few relatively short intervals in the United States. For example, model clinics (which I call “academic platforms” because they serve as sites for research and teaching) staffed by U.S. academics and their students could provide the initial levels of training to learners within their own countries, but in a setting approximating what they would find in the United States. The U.S. academics would be attracted to work in such clinics partly because they could practice in a manner that more closely resembles the way they practice in the United States.

Once the students had reached a defined level of competence—not only in clinical skills but in language and culture skills—the most promising would be admitted into highly focused courses of study at U.S. academic health centers that would be relatively short (e.g., six to 12 months) and designed to give the students knowledge and skills they could apply in their home settings, particularly in the model clinics. Yet the much shorter time period (months instead of years) would lessen the tendency of the students to totally assimilate into U.S. society and thus be less likely to fit in back home. Upon return to the home country, the learner would ideally retain an ongoing relationship with the model clinic for purposes of education, research, and patient care. The collaborations established while in the United States would be essential to the students' ongoing success in research and patient care upon their return home. And the presence of the Western-style model clinics would be an additional encouragement for the students to pursue their medical careers in their own countries, since they could apply more of what they had learned and also might be able to fill staff openings upon graduation.

Though public health and primary care medicine should remain focus points for health care initiatives in developing countries, the need for specialized care is growing. Academic health centers in the West have an opportunity to help keep specialized care in balance with the more general health care needs in those countries and at the same time could help preserve specialist training programs in the United States. These goals could be achieved by facilitating international students' entry into U.S. specialist training programs that have been curtailed because of an overabundance of specialists in the United States.

In addition, these specialist training programs are often accompanied by requirements for research. Skilled researchers are desperately needed, both in developing countries and in the West, and encouraging international students to learn and use research skills would help fill this need in both worlds. Indeed, many of the most creative and productive researchers in the laboratories associated with U.S. academic health centers are from overseas. It is important not to lose sight of the fact that it is the contributions of our research base that have resulted in the high-quality practice standards found in the United States.

How do U.S. academic health centers benefit from the education component of the relationship proposed above? First, the establishment of academic platforms in foreign countries will provide a higher caliber of trainees to the United States, as well as mechanisms to properly evaluate those applicants. These trainees will be more likely to enhance the academic units where they are working either in patient care, research, or other scholarly activities. This will allow the United States to identify and attract the top applicants, who will have long-term relationships with their institutions. Second, such a platform provides an excellent venue for the evolving technology of telemedicine and longdistance learning that is being developed by many academic health centers. Third, this platform provides an excellent clinical venue for rotating U.S. trainees. This last point deserves particular attention.

The deans of most U.S. medical schools, as well as the program directors of many clinical training programs, are quite aware of the attraction among U.S. students and residents for rotations in foreign countries. Many institutions have pathways that allow students and residents to spend time overseas. For example, the internal medicine program at Duke University has demonstrated the value added to its residency by international experiences, the availability of which can be a determining factor in residency selection.4 Many programs advocate the teaching of dedicated curriculums about tropical diseases or travelers' medicine. Institutions such as The Johns Hopkins University School of Medicine, Tulane University School of Public Health and Tropical Medicine, and the Gorgas Memorial Institute at the University of Alabama School of Medicine have established in less-developed countries successful courses of study that focus on diseases and public health issues not commonly encountered in the West. However, most U.S. trainees rotating overseas are not enrolled in such formal courses and experience clinical situations of variable instructional quality. Critics argue that such experiences, though life-enriching, are not valuable components of a medical curriculum. To counter this I offer the following views.

One of the glaring deficiencies of many current U.S. medical curriculums is the absence of training in translating what is acquired in an academic health system into settings less endowed with expertise, finances, and medical resources. In addition, one goal of medical training has been to make the trainees familiar with as many different diseases as possible, to better recognize them when encountered later in practice. This should remain a desired outcome. However, I would also argue that learners should be exposed to as many different practice settings as possible. It is in this variety that learners can both become familiar with a wide spectrum of diseases and learn to translate the principles acquired from academic health centers into practice. Such exposure is important, since, as many would argue, the clinical learning environment associated with most U.S. academic health centers is not varied enough. Attempts at gaining wider access to community hospitals and practitioners suffer from their own time, financial, and legal constraints.

We already know that we must train our learners to practice far outside the confines of teaching hospitals. Applying acquired knowledge to settings with limited resources and bureaucratic barriers is a constant challenge to physicians in all areas of medicine. A curriculum that gives students the skills to make such applications is best achieved by rotating them through a variety of practice settings, and I believe that these should include settings in the larger global community. Training settings in less-developed countries encourage students to develop the problem-solving skills that attract many to the field of medicine, a process that many find highly rewarding. Exposure to diseases not previously encountered is clearly a valued goal of overseas experiences. However, encounters with common diseases in uncommon surroundings offer powerful learning opportunities. Responding with good care within the limits of the health care setting often requires creative solutions and gives the kind of satisfaction that many physicians seek.

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CLINICAL SERVICES

The global market will require reliable health care services in foreign settings, particularly in less-developed countries with emerging markets. As employees of multinational corporations spend more time overseas, health care provider networks will be needed overseas also. The U.S. health care industry could benefit by entering these markets with a goal of establishing cost-effective health care systems that are appropriate to the needs of both the multinational community and the local one. In some ways, establishing such systems may be easier to do in regions with emerging economies than in the United States, where the conflicting agendas of consumers, providers, and payers may at times inhibit implementation of new approaches to health care. Many could argue that the inefficiencies and lack of “consumer responsiveness” commonly found among U.S. academic health centers make them less well suited than are for-profit ventures at rendering these international services. However, I believe that defining, establishing, and refining these systems should be in the domain of the academic health center. The permanence of multidimensional, diversified academic platforms that U.S. centers offer would be attractive to the local and international business communities. This, in turn, could result in a greater ability to raise capital from the private sector, to the benefit of the host country. U.S. academic health centers usually benefit from high prestige among many foreign governments and the international business community. This advantage can be capitalized on not only by harnessing the ability of the centers to provide academic platforms as previously stated but even more by taking advantage of their ability to make available consumer-driven, cost-effective care in the overseas environment.

An overseas clinical care delivery system that is closely linked to the international academic medical community can also serve as a monitoring system for emerging diseases and epidemics. This point was emphasized during the outbreak of infection with the avian flu virus in Hong Kong in late 19975. In Hong Kong, pathways existed between the public health community and the Centers for Disease Control in Atlanta such that reliable information regarding this epidemic was forthcoming on a timely basis. In contrast, in Shanghai, although many suspected the origins for this epidemic to be in mainland China, there was no information regarding the epidemiology of this outbreak in our community. It is also important to note that many developing countries view diseases such as TB and HIV infection as stigmatic; consequently, the incidences of these illnesses will be underreported or at least downplayed in importance. In such countries, maintaining a regular on-site presence of members of the international health community is the most likely way that access to reliable information can be obtained.

A recent report from the Institute of Medicine6 argues convincingly that U.S. interests are well served by participating in global health initiatives for the following reasons. First, increasing numbers of American citizens are traveling abroad, risking exposure to diseases outside the United States that can then be brought back home by travelers and returning expatriates. It is estimated that 1 million individuals travel between the developing and industrial worlds each week,6 facilitating the dissemination of disease previously confined to select regions. Exposures to infectious diseases previously thought of as exotic will increase. Knowledge of disease patterns in different parts of the world will be essential to good care for both traveling Americans and newer members of American communities who may bring with them diseases indigenous to their countries of origin. Though this circumstance is perhaps most obvious for infectious diseases, biohazard exposures from environmental pollutants and potential instruments of biological warfare must also be considered. Second, the U.S. economy would be better served if the economies of the world were less burdened by disease, particularly those of the less-developed countries that make up a substantial component of emerging markets. To site an example in the United States, it was estimated in 1985 that the $32 million invested by Americans to eradicate smallpox is returned every 26 days through reduction in the need for vaccination, monitoring, eradication, and treatment programs.7 Finally, U.S. medical knowledge, as acquired through institutions such as the National Institutes of Health and Centers for Disease Control, can be an instrument of good will that fosters medical progress in other countries and thus promote U.S. interests.

If academic health centers are to have a clinical presence overseas, who would staff them and provide the care? I believe that the kind of academic health center-overseas country partnerships described earlier could answer these needs. Many U.S. faculty members would probably welcome the opportunity to work overseas for defined intervals if temporarily freed from their responsibilities in their home departments. While in China, I was impressed with the number of U.S. faculty members interested in working with us in Shanghai. In fact, I was approached by more volunteers from U.S. academic centers than I could accommodate. The growing community of retired physicians and caregivers who have abandoned careers in the United States because of recent pressures represents another valuable pool. Over time, more of the staffing would be provided by physicians from the home countries who had returned after training at the partner academic health centers.

Numerous pitfalls await those hoping to establish clinical services in developing countries. Patience is required to work through both regulatory issues and legal systems that are much more susceptible to corruption than those that are usually found in the United States. From my experience in China, one area that is particularly worrisome concerns the often unregulated application of technology. This was particularly apparent in the pharmaceutical industry. In 1995, 1,674 producers of pharmaceuticals were registered in China, of which only 10% had formal relationships with foreign pharmaceutical concerns.2 Many in China believe Western drugs have extra healing powers and are better at addressing symptoms, while the slower methods of traditional Chinese medicine are better at dealing with the underlying etiology. A wide variety of locally made “Western medications,” particularly antibiotics, can be obtained, often with attractive western packaging. Interpretations of patent laws and the concept of “intellectual property” are unrecognizable in China to those familiar with these concepts in the West. Proprietary drugs are often quickly copied and placed on the local markets at substantially lower cost. Thus, Western pharmaceutical firms have a difficult time developing positions in China, which with 1.3 billion people is the largest developing market in the world. This in turn results in very aggressive marketing practices and unique relationships with hospitals. Pharmaceutical sales typically generate 60% of the hospital revenue in Chinese hospitals, compared with 10–15% in more developed countries.2

Though these practices are perhaps improper, what is the problem with them for the West? Based on my observations in China, there are three major problems. One is the large outlay of money to purchase a wide variety of expensive boutique medications that may not be appropriate for the patient. Because a medicine is expensive or foreign, it is presumed to have greater healing properties. Often the money would be better directed to proper testing and diagnosis, with the use of less expensive medications whenever possible. Second, the lack of quality control and regulation may result in products of questionable safety and efficacy. For example, a large outbreak of deaths from hemolytic uremic syndrome in Haiti in 1996 was eventually linked to cough syrup from China that was contaminated with diethylene glycol.8 Finally, and perhaps most alarming, is the overreliance on antibiotics, often used only in brief or erratic intervals to treat a multitude of ailments unlikely to benefit from antibiotics. In many parts of Asia, patients feel that their illnesses have not been properly acknowledged if an infusion of antibiotics is not provided. Intravenous antibiotics are used liberally, resulting in a revenue benefit to the hospital and often an incentive to the ordering physician. However, antibiotic resistance makes new drugs impotent sooner than they normally would be through the spread of resistant organisms via travelers to all parts of the world.

How can academic health centers in the United States play a positive role in these scenarios? Model practices with academic values can counterbalance the profit motive of the emerging global health care marketplace with the needs of the communities in developing countries. Collaborative academic platforms involving academic health centers could better attract and control meaningful partnerships with multinational corporations in need of clinical services as well as with pharmaceutical companies in need of markets. The potential for corruption, ever-present in emerging markets, must be kept in constant view. Overseas pharmaceutical companies can be held to the better standards such companies observe in developed countries, with more open practices that can be viewed and monitored by the wider community.

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RESEARCH AND EVOLVING TECHNOLOGIES

Research

Research opportunities in differing regions of the world offer the most apparent positive benefits to academic institutions in the United States, most of which have investigators who are participating in international collaborations. However, there is rarely a unified institutional effort on the part of an academic health center to further its faculty's global research efforts. For example, certain diseases are more concentrated outside the United States, where study of their natural histories and treatment modalities is better accomplished. In China, viral hepatitis, Helicobacter pylori infection, and malignancies of the upper gastrointestinal tract are a few of the diseases of this type that come to mind. Much of our knowledge regarding vaccine development and efficacy, as well as treatment of tropical infectious diseases, comes from investigational work in developing countries.

It must be kept in mind that research in less-developed regions, which have potentially vulnerable populations, is not without the risk of ethical improprieties. Safeguards for interventional studies in accordance with international standards must be in place and monitored by the greater academic community. This will become even more important as pharmaceutical companies move many of their clinical trials offshore, in part to reduce the high costs associated with clinical trials in the West. Academic health centers are well positioned to ensure that standards applicable in the United States are used internationally.

Two areas that are particularly pertinent to developing countries are applied technology and health services research.

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Applied Technology

Technology is the easiest component of Western medicine to transport to developed countries. Advanced computed tomography and magnetic resonance imaging machines, sophisticated endoscopy equipment, and supplies for coronary artery stent placement are all readily available in many large cities of the developing world such as Shanghai. Indeed, these are assets often touted when speaking of an advanced hospital or expert health care system. However, training in the application and interpretation of such modalities often lags considerably, and poorly maintained equipment is commonplace. Similar to the profit incentives associated with Western pharmaceuticals, these technical modalities often represent an important revenue stream, and their application is unregulated. With the race for market position within emerging countries, companies can easily justify large subsidies, or outright gifts of equipment, in hopes that the future “need” for such technology will grow with the economic welfare of the state. With the introduction of market forces into the Chinese health system, many are unprepared to sort through the conflicting agendas that, if left unchecked, lead to inappropriate expenditures. If properly structured, I believe that collaborations with academic health centers will offer a unique, critical assessment of opportunities and legitimate partnerships with industry. Historically, partnerships between academic health centers and industry have been an important factor in the successful implementation of technologies in the West. Moreover, academic health centers can provide to the professionals in the developing world the intellectual “capital” needed for the appropriate application and use of these technologies.

An area that stands to prosper overseas, perhaps more than in the West, is telemedicine. In the United States, this technology is more sophisticated than the current level of usage implies. The wide dispersion of expertise around the United States, mobility of patients, and problems with payment for services, particularly when teleconsultation crosses state lines, are some of the reasons this technology has not realized its full potential. However, telemedicine is particularly attractive for overseas applications, where imported expertise is particularly valuable. In Shanghai, there is a substantial executive community and most are critical consumers. If a serious ankle injury requires surgery, they prefer to leave the country for care in Hong Kong, Singapore, or Japan. However, if a simple cast is all that is needed, they prefer care in Shanghai, saving the time, expense, and, at times, difficulties with travel papers. Through telemedicine consultations with orthopedic surgeons in home countries viewing the x-rays and other pertinent data online, a plan for diagnosis and treatment can often be rendered from outside the country, making travel unnecessary. This cost savings would be offset in part by the funding required to maintain this system and to compensate the consulting units. With the ever-evolving Internet, telemedicine of the future will be more feasible and less expensive than the present telemedicine associated with satellite transmission or leased lines. One reason telemedicine will become popular is that patients, regardless of their countries of origin, are most comfortable knowing what good doctors from their own culture would do to treat their illnesses or injuries. Also, once established, this telemedicine infrastructure can be instrumental in facilitating the education programs noted earlier.

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Health Services Research and Application

Like most institutions in the West, Chinese hospitals are experiencing spiraling costs as they move toward the asymptote of the cost—benefit curve. Private health care insurance is cautiously being tested and will undoubtedly evolve. Prices for health care services are fixed by the state and published in a price guide (the “yellow book”9). Select joint-venture clinics are at times able to increase these prices by several-fold. With few exceptions, there is no concept of private practice in China.

Through partnerships with foreign academic health centers, U.S. academic units may be able to participate in the construction of delivery systems that make use of principles acquired, often in hindsight, in the West (the tendency to allot more resources for treatment than for prevention; the attraction of high-tech gadgetry at the expense of basic primary care, etc.). Hopefully, these delivery systems could be constructed using and adapting knowledge that has been acquired in our own system (i.e., learning from what has worked and what hasn't in terms of cost-effective care for populations) as opposed to being fashioned according to government edicts whose efficacy has not been substantiated.

Collaborations between U.S. and Chinese academic health centers could be of mutual benefit in the study of public health issues such as smoking. It is estimated that if current smoking uptake rates in China persist, tobacco will kill about one third of the 300 million men now under the age of 29, and that of these deaths, half will occur during middle age.10 The lack of knowledge among the population regarding the hazards of smoking is worrisome. The importance of appropriate “starting points” for education programs was illustrated poignantly to me during a recent seminar. In 1998, colleagues from the University of Michigan Medical School were invited to present information to the Shanghai Medical University School of Public Health regarding smoking-cessation programs. This institution, as one of the leading public health units in China, was being charged by the government to lead the way in reducing smoking rates by at least 1% per year in the community and in fact had designated itself one of the first smoke-free units in China. I witnessed an excellent presentation by my colleagues, complete with the most commonly employed smoking-cessation education and motivational programs that are used in the West. The local faculty seemed most curious about this “physician-centered” information, and many good questions followed. However, we were all taken aback to be informed that most patients in community or rural settings give gifts of cigarettes to their physicians, who in turn smoke during the patients' visits. Foreigners often fail to understand cultural nuances that affect health care delivery and research. These nuances can be best addressed through long-term relationships between colleagues from institutions in the East and West, where differences and opportunities can most easily come to light.

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Importance of History

Failure to understand the culture or historical background is a common pitfall in joint-venture relationships. However, for partnerships with China, a country with a population fivefold that of the United States, starting points must incorporate knowledge of recent history. For example, much of the medical establishment is still realizing the effects of the Great Proletariat Cultural Revolution, a time in China between 1966 and 1976 when Chairman Mao Ze Dong rewarded youths for returning to the work ethic of the peasants and laborers who constitute the majority of the population. In his 1965 directive on medical education he stated:

Medical education should be reformed. There is no need to read so many books. In medical education, there is no need to accept only higher middle school graduates. It will be enough to give three years to graduates from higher primary schools. They would then study and raise their standards mainly through practice. The more books one reads, the more stupid one gets. We should leave behind in the city a few of the less able doctors who graduated one or two years ago and the others should all go to the countryside. In medical and health work, put the emphasis on the countryside.”11

With that, most medical school faculties were sent out into the countryside to learn from their peasant colleagues. Others were placed in power and leadership positions because of their adherence to these values, at the expense of true medical learning. Medical schools were closed (with the exception of those affiliated with the military) and not fully reopened for five to ten years. I did well to keep in mind that those who were educated and trained prior to the cultural revolution are now entering retirement. Those who trained and prospered during those difficult years did so in part by having—or at least expressing—a certain level of contempt for the West and its values. These are the people who are currently in leadership positions within the academic health centers of China. Success in joint programs will come only after a long courtship with clear and realistic dialogue about goals, the components of which will take years to mature.

History also provides examples of successful academic co-operative efforts between the East and the West. In 1915, the Rockefeller Foundation purchased Peking Union Medical College, which for many years served as a premier multidimensional institution within China, providing education, clinical service, and research opportunities for many years prior to the 1950s, when the institution became nationalized. There are also current examples to be cited, the most prominent of which is one being piloted by The Johns Hopkins University in conjunction with the National University of Singapore. Johns Hopkins Singapore, Private and Limited, is a joint venture that will provide a structure in Singapore for coordinated tertiary care clinical services, as well as education and research collaborations between the two institutions. This unit12 opened, with an initial focus on oncology, in April 1999. The creation of such overseas structures requires familiarity with the culture, which can stem only from long-term partnership and continuous presence.

Various mechanisms have been in place to support funding of global health initiatives by academic medical centers,13 with prominent programs such as the National Institute of Health's Fogarty International Center and U.S.A.I.D having enjoyed great success. Nongovernmental organizations such as the China Medical Board of New York have been instrumental in funding research and educational initiatives in Asia. Foundations and academic institutions will enjoy more maneuverability in the international community if they are not viewed as arms of the U.S. government.

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TAKE-HOME MESSAGES

Many readers will recognize that global health initiatives are currently taking place at their own institutions. Indeed, most academic health centers already have research projects, scholar exchange programs, or other focused initiatives with at least one other academic medical center outside the United States. For those of us in the West, the tendency is to start small and hope that our programs will evolve into multidimensional initiatives. However, many colleagues in countries abroad will see this approach as one representing limited enthusiasm and commitment. The major point that I wish to make with this article is that global health initiatives can work best only through the establishment of a platform that is multidimensional and anchored with permanence in another part of the world. For most host countries, the creation and maintenance of a long-term relationship is what matters most. Americans and others from the West are often viewed as exploitative, with agendas that are not always good for the host countries. The complexities of working in a foreign environment necessitate long time frames and long-term goals. Funding in the United States is often over relatively short intervals with very targeted objectives within a preset time line. This approach is culturally foreign to many in the East. U.S. institutions will need to take risks and revise their expectations for a quicker assimilation into foreign settings. The success of any global health initiative will likely not be apparent for at least ten years.

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REFLECTIONS AFTER RETURNING TO THE UNITED STATES

In closing, I can't help but reflect on realizations I had while working outside my home culture. I hope these realizations will make me a better clinician and a better academic. First, the interdependence between the local culture and medical care was illustrated to me with ringing clarity. With patients from all different countries and walks of life, we had to spend more time understanding their expectations for a visit to our clinic. What they thought was needed was often quite different from what I thought was needed.

Second, I am more aware of the impact that individual freedom has in relation to information and education. One particular strength of our U.S. system is the freedom learners have to pursue evidence and, if necessary, challenge their teachers. This is, of course, quite dependent on the learners' having access to the evidence, which is often not the case in developing countries, in part due to limited materials and data but also due at times to a reluctance to let data see the light of day. Frequent references to the literature or retreats into textbooks, often a valued attribute of learners in the West, can, in fact, be viewed as a sign of weakness in some regions. In many training systems, the viewpoint of the teacher is the “gold standard” and the only one that matters. Scientific literature is used infrequently and only when it substantiates the teacher's opinion. Access to evidence in the literature by learners will be a threat and must be gently introduced into hierarchical systems that are largely based on the unquestioned authority of their leaders. The culture of learning needs to be transmitted as much as the knowledge that is being mastered.

Third, I'm reminded of the dangers of ignoring the preferences of patients and their definitions of good care in the communities where we work. To fail to take such views seriously smacks of elitism. In the West, we should be able to show to consumers the value of academic medicine and of academic health centers. Unfortunately, the most superficial markers, such as the user-friendliness of a hospital, are all that many consumers can recognize, and from them they will extrapolate their opinions of the entire health care system. A failure to respond acutely to the perceptions of the community in which we serve, here or abroad, will yield a smugness that will in turn be our downfall.

Finally, I've been reminded of the importance of creativity within medicine. Indeed, fostering creativity has been one of the hallmark sacred values of the academic health center, even if it is not always practiced. In contrast, the society and culture I found within the medical system in Shanghai is very proscribed. Individual creativity and problem solving, particularly by junior physicians, is much more risky than conformity. This absence of a creative outlet deprives the hospital settings of ingenuity, driving learners to study elsewhere. In looking back at the academic realm of the United States, I think that we, too, must be careful that we do not frustrate scholarship and creativity. A number of our best and brightest who have interests outside traditional basic science research find it hard to express their creativity within the rigid definitions of scholarship found in many academic health centers in this country.

I have argued that it is important for academic health centers to be active in global health initiatives. Admittedly, my observations may be unique to China, but I suspect that many would apply to a wide variety of overseas settings. It is important to note that we will not be greeted abroad with open arms. Our ability to establish lasting and mutually useful relationships will be tested again and again. We must realize the advantage that we and our predecessors in U.S. medicine have had in working through problems to gain the vantage point we currently hold in teaching, research, and patient care. To expect others to quickly share these vistas is unrealistic, and chiding them if they do not do so will only increase the gap. Partnerships must be constructed with institutions in less-developed regions so that both parties benefit in the areas of education, research, and patient care. Academic health centers in the United States have a unique opportunity and an obligation to form these partnerships to meet the challenges of global health.

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*For example, charges typically rendered in 1998 at the highest class (i.e., tertiary class) hospitals in Shanghai were: outpatient consultation, $1; hospitalization (i.e., bed charge per day), $3; X-ray, $3; EKG, 85 cents, and CT scan $25.2 Cited Here...

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