Stapleton, F Bruder MD; Wahl, Patricia W. PhD; Norris, Tom E. MD; Ramsey, Paul G. MD
In 1989, Robert G. Petersdorf, then president of the Association of American Medical Colleges (AAMC), and Kathleen S. Turner, then AAMC assistant vice president, wrote about the roles and responsibilities of United States medical schools in international medical education.1 The authors called for a more active U.S. role in international medical education, citing a number of reasons, including the fact that disease knows no boundaries and research must similarly be blind to political boundaries.
Nearly 20 years later, international health is very much on the minds of Americans. Concern about the health of the world’s population has increasingly gained attention as a result of major global social, political, and environmental crises. The HIV/AIDS and SARS epidemics clearly demonstrate how the health challenges of developing nations affect more established societies.2 Political and geographic borders do not stop communicable diseases, and the distance between the developing world and the industrialized world is shrinking rapidly. Students who pursue careers in medicine and public health are increasingly asking how their education can prepare them to make personal and system-based contributions toward solving global health problems.3 Students and residents who complete international electives find that the experience has a profound impact on their social and medical perspectives and career choices.4–9
Major global health initiatives are more common in schools of public health than in schools of medicine. Because there are concerns about using state funds to support global initiatives, such initiatives are far more common in private schools than in public schools. Frequently, international health initiatives in schools of public health and schools of medicine are individual or departmental efforts, often in response to extramural funding opportunities, and they seldom involve widespread integration of faculty from both schools. However, separate or isolated efforts may not be as effective as collective, coordinated initiatives.
The University of Washington (UW) has a panoply of global health programs housed in widely diverse settings, such as the schools of arts and sciences, business, public affairs, law, education, nursing, dentistry, public health, medicine, and others. These include curricular offerings, faculty and student exchange programs, degree programs, clinical trials, clinical service opportunities, and public-health and population-based initiatives. Recently, in recognition of the importance of global interactions, UW revised its mission statement to emphasize the university’s responsibility to improve the health and well-being of the global community. A university-wide position of vice provost for global affairs was also created to oversee and promote global activities.
The health sciences program at UW has always strongly emphasized infectious diseases research and clinical trials, clinical service, development and implementation of public-health infrastructures, epidemiologic studies and surveillance systems, and vaccine development and delivery. These programs have been based in either the School of Public Health and Community Medicine or the School of Medicine. UW currently has eight Fogarty Centers funded by the National Institutes of Health (NIH) to support international research and training. These centers provide international research training experiences in various infectious diseases, bioinformatics, occupational and environmental health, injury prevention, and population-based child health. The Fogarty Centers are independent from one another and have no central campus around which to focus their shared missions. Three years ago, the diversity of international exchange programs among the many health-sciences programs, coupled with the availability of private funding, led to the creation of the Global Health Resource Center to coordinate student services and educational activities in global health. Even this resource center’s efforts, however, could not meet the strong demands for international experiences from students and faculty.
To better meet the increased demands and with the goal of addressing some of the most critical global health challenges, UW has created an innovative Department of Global Health that is based jointly in the School of Public Health and Community Medicine (SPHCM) and the School of Medicine (SOM). This department will facilitate development and implementation of a cross-cutting vision for advancing global health by expanding and initiating interrelated local and international educational programs, multidisciplinary research centers, programs in global health care and practice, and population-based health activities. In this article, we review the process by which this department was created and what it expects to accomplish.
Development of a Concept
In 2002, the UW SPHCM convened a task force to perform an environmental scan of the strengths, weaknesses, and opportunities related to international health in the school and to create a strategic plan to become a leader in global public health. The task force, composed of public-health and medicine faculty and students in addition to outside consultants, recommended the establishment of a Center for Global Health to support international work by faculty, staff, and students. A new institution-level program was deemed essential to coordinate these relationships and raise them to a new plane. The center would strive to create experiences for faculty and students worldwide, promote research, improve practice and policy, and promote social justice and address health disparities among low-income populations. These goals would be accomplished through the integration of education and research across academic disciplines. The task force recommended that the center work toward the admirable and daunting mission of achieving global health equity.
In response to the recommendations of the task force, the deans of the SPHCM and the SOM crafted a bold concept—the creation of a Department of Global Health to be jointly administered between the two schools. A similar dual-school Department of Bioengineering, which has been highly successful in UW’s College of Engineering and School of Medicine, was the model for such a “marriage.” Bringing experts in public health together with leaders in biomedical research and international clinical care to address critical problems in the world’s health would facilitate new approaches and create unique opportunities for students at our university. This concept was met with substantial enthusiasm within UW’s administration and presented an opportunity to approach the Bill and Melinda Gates Foundation, which has invested heavily in global health issues, to explore their interest in providing funding to develop a Department of Global Health and recruit an initial leader. The concept of a unique department that combines the strengths of two nationally recognized schools with expertise across multiple disciplines, along with the ability to coalesce the many international health programs throughout UW, garnered a significant grant from the Bill and Melinda Gates Foundation. This gift launched the process to create the first dual department within the SPHCM and the SOM.
Planning and Creating a Department of Global Health
In November 2004, the dean of public health and community medicine and the dean of medicine convened a Global Health Advisory Committee with the following charges:
* Assess support for the concept of a new department and the potential for collaboration among and within the SOM and SPHCM, other health-sciences schools, and related units of UW;
* Define the mission of the department and the scope of its programs; and
* Serve as a search committee for the founding chair of the department.
To obtain broad input to inform its recommendations, the Global Health Advisory Committee conducted over 200 interviews within the university and Seattle community, organized student focus groups, and conducted an open university-wide forum.
The advisory committee found an extremely high level of interest and enthusiasm throughout the UW community for development of a Department of Global Health. The committee was consistently urged to develop a broad scope of research (including both medical and applied research), to think creatively, and to maximize opportunities to bridge public health and medicine in global-health research at UW. All advisors felt that it was important for the new department to conduct applied practical and sustainable research and to have service programs in developing countries. One of the greatest opportunities perceived for this new department was creating education and training programs at all levels, both at our university and with global partners. Finally, committee members repeatedly emphasized that an array of exceptional global health programs already existed in the Seattle community and that partnerships should be formed to bring added value whenever possible.
The advisory committee recommended the creation of a unique, interdisciplinary department of global health dually based within the SOM and the SPHCM. This department would bring added value to the many successful global programs at UW and in the Seattle community through creative and innovative coordinated public health and medical approaches to major global health programs. The department would strive to develop internationally recognized educational programs and conduct applied international research in developing countries, as well as conduct biomedical research and provide health care services worldwide. The foundation of the department’s mission would be striving towards the ultimate goal of global health equity.
The advisory committee concluded that UW provided a strong environment for creating a world-class global health department. The committee cited the following reasons:
* Existing research and educational strengths in the SPHCM and the SOM;
* Well-established global health programs in the Schools of Nursing, Pharmacy, and Dentistry;
* Excellent international education and service programs in the schools of law, business, arts and sciences, and others;
* A record of successful cross-disciplinary collaboration at UW and between the SOM and the SPHCM;
* A vast array of outstanding global health enterprises in the broader Seattle community (e.g., the Fred Hutchinson Cancer Research Center, the Program for Appropriate Technologies in Health, and the Seattle Biomedical Research Institute);
* Extraordinary and pioneering expertise in information technologies at UW; and
* Ubiquitous interest and enthusiasm for global health among UW undergraduate students, medical students, graduate students, and residents.
The advisory committee envisioned the Department of Global Health as developing cross-cutting initiatives in research, education, and global health care and public health practice (Figure 1).
In February 2006, the UW Board of Regents approved the creation of the Department of Global Health in the SPHCM and the SOM.
Education Plans for the Department of Global Health
The Department of Global Health will increase the number and scope of global-health courses to create a more complete global health curriculum at UW, and it will also offer a full range of advising and mentoring activities for students. These offerings will be available not only to traditionally matriculated students of the SPHCM and SOM, but also to undergraduate and graduate students from the entire UW campus. In addition, coursework in the department will be available beyond the UW campus, using UW’s well-developed infrastructure for distance learning. When fully implemented, global health coursework will become an integral component of the university’s undergraduate and graduate educational programs. Initial priority areas for curricular development are shown in List 1.
The department is expected to increase demand for global-health courses by creating new programs and degrees and enhancing successful existing programs, such as the International Health MPH Program and the Peace Corps Master’s International program. An MD/MPH combined degree that can be completed in five years is also being considered for medical students. Many existing medical school residents are interested in academic medicine. An MPH/primary care residency combination that requires one additional year of training presents an exciting prospect. A Doctor of Public Health program with an emphasis on global health is also being considered. The advisory committee recommended that development of an expanded curriculum receive the highest priority of the new department.
Global Health Research
International health research must be a central component of the Department of Global Health. Research activities will build on an impressive array of existing programs in both schools, including the eight NIH Fogarty Centers, over 122 foreign subcontracts for health-sciences departments, the Seattle Vaccine and Immunizations Research Center, the Puget Sound Partners Global Health Research and Technology Program, the HIV/AIDS Clinical Trials Leadership, and others. Recently, UW was awarded a Fogarty-Ellison grant to fund international research. Other key opportunities for collaborative global health research exist with the Fred Hutchinson Cancer Research Center. A large number of faculty in the departments of microbiology, pathobiology, laboratory medicine, immunology, and internal medicine have grant-funded research focused on parasitic diseases, sexually transmitted diseases, tuberculosis, and hepatitis C. Other research groups are addressing multidisciplinary approaches to genetic or infectious contributors to chronic diseases, obesity, diabetes, depression, maternal and child health, and vaccine development. These laboratories are dispersed throughout UW’s campuses. While the vast majority of these departments would not change affiliation, the Department of Global Health will encourage collaboration, identify new funding opportunities, and establish the infrastructure to facilitate research among different laboratories in global health topics. The advisory committee also recommended a focus on global population and health research and population modeling. Increased global health research training for UW students, as well as for international students and faculty, will be a mission of the new department.
The major goals of global public health research are to understand the determinants of health for diverse populations and to develop effective strategies to improve health and reduce health disparities. The agenda challenges traditional models of single-discipline research for two reasons. First, the determinants of population health are complex, involving interactions of biomedical, social, and individual factors both within and, due to the forces of globalization, across geographically distinct populations. Second, the elements of this system are dynamic, and the evolution of these forces as they interact and adapt has both short- and long-term consequences for population health.
A growing movement in global public health research is the synergistic convergence of the fields of demography and population studies with the fields of macroeconomics, epidemiology, public health, and medicine. For example, the Wellcome Trust recently shifted its focus in population research from “Population Studies” per se to “Population and Health Studies.” The Bill and Melinda Gates Foundation and World Bank support the Disease Control Priorities Project, establishing partnerships between macroeconomists, public health specialists, and clinicians in surveying global health disease control priorities. The advisory committee recommended development of a population-modeling program in global health research at UW. Initial efforts to create mathematical modeling have begun in the UW Center for AIDS Research. Specific faculty recruits have centered on this effort.
Global Health Care and Public Health Practice
Working to achieve global health equity is an important mission of the Department of Global Health. To accomplish this, strategically selected global health service initiatives must be a departmental priority. At most universities, service frequently is less prominent than research or teaching. This is reflected in the fact that service activities do not receive much credit for faculty promotion purposes. Formal medical and public health literature also neglects this aspect of professional activity. Nonetheless, service activities have the potential to contribute to lowering the burden of death and disability globally. In discussions, students voiced strong preference that this aspect of the mission be considered of equal importance with education and research. The quality and success of existing programs, both at UW and in the Seattle area, provide an ideal environment for leadership and the creation of new initiatives.
Service, as defined by the advisory committee, includes the application of the results of research on health problems, services, and policies, and covers the following areas:
* Technical assistance programs, such as UW’s International Training and Education Center on HIV and Health Alliance International;
* The provision of direct clinical services;
* The provision of public health services;
* Efforts to strengthen the health care infrastructure and the public health infrastructure through:
* operations research,
* training both for students and for practitioners in international sites, and
* advocacy, including addressing broader determinants of health inequity.
The provision of clinical services is characteristically given considerable importance in schools of medicine, especially at their own teaching hospitals, but less so at international sites. Nonetheless, a growing number of medical students, residents, and other health professionals seek international elective rotations and other opportunities to provide clinical care. The UWSOM has a clinician–teacher pathway for faculty that recognizes clinical practice and teaching as academic priorities.
Provision of public health services has not typically been a priority of schools of public health. The UWSPHCM has been an exception to this. One key effort has been the Northwest Center for Public Health Practice, which provides practice-oriented education and training programs for practitioners in public health agencies and community-based health centers. The center works with health agencies throughout the Northwest in developing these programs. The center’s latest work has been in bioterrorism preparation, which affects many countries. Expansion of such training into global health projects will occur in the new department.
Challenges for the Department of Global Health
Office space, laboratories, and faculty recruitment create normal challenges to the inception of a department. These are especially challenging at UW where the campus, faculty, and student body are growing. Facilities, laboratories, and teaching space are distributed across multiple locations throughout Seattle. These factors create challenges in carefully planning space, achieving travel efficiency, and ensuring the development of a strong sense of community despite distances. Coordination across two schools adds to this challenge; the proximity of the formal offices of the SPHCM and the SOM somewhat alleviates this concern. In addition, the Department of Global Health, with faculty of various backgrounds and scholarly interests, will create the need to develop specific promotion pathways, research infrastructure, international grant management, and innovative funding mechanisms. Having established expertise in arranging IRB approvals at international locations, shared funding agreements for international clinical-research studies, and standard human-resource requirements for both local and international faculty will facilitate new international relationships and reduce major barriers for implementing programs.
The creation of a UW Department of Global Health has generated both widespread enthusiasm and significant anxiety within the university community. Concerns were expressed by faculty with years of investment in global health issues that hard-won resources for their program would be redirected and that a new department would reduce the independence of established programs. Extensive efforts to communicate with and reassure these individuals and programs have reduced concerns. For example, the Global Health Resource Center, currently an invaluable multischool resource, feared that its function would be replaced by the new department. Instead, the Resource Center will move into the department and, as a result, will enjoy greater infrastructure support. Departments in both the SOM and SPHCM had concerns that well-funded faculty might wish to transfer their primary appointment to the new department, which would destabilize the research environment and funding for existing programs. To minimize these concerns, recruitments to the new department will be primarily external. Extensive discussions with SOM and SPHCM chairs occurred throughout the development of the department and the recruitment of the chair. Nonetheless, transparency and thoughtful communication will continue to be required as the department moves forward.
The most impressive lesson gleaned from the process of forming this unique department has been the enthusiasm of both public health and medical students for the endeavor. Today’s students have a remarkable awareness of globalization and a passion to improve the health of less advantaged populations. Witnessing this energy has been inspiring to the advisory committee and to chair candidates during their visits.
The Marriage Begins
UW has founded a unique Department of Global Health using both public and private resources. Widespread student and faculty enthusiasm has generated strong initial support for the new department. Creating truly novel approaches as a result of the public health and biomedical marriage will depend on the vision and ability of the founding faculty to fully represent and support both disciplines. The opportunity is great and anticipation of success is high.