Houpt, Eric R. MD; Pearson, Richard D. MD; Hall, Thomas L. MD, DrPH
Dr. Houpt is assistant professor of internal medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, and chair, Committee on Education, American Society of Tropical Medicine and Hygiene.
Dr. Pearson is professor of internal medicine, Division of Infectious Diseases and International Health, and Pathology; and senior associate dean for medical education, University of Virginia School of Medicine, Charlottesville, Virginia.
Dr. Hall is lecturer, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, and executive director, Global Health Education Consortium, New York, New York.
Correspondence should be addressed to Dr. Houpt, Division of Infectious Diseases and International Health, University of Virginia, 409 Lane Rd., MR4 Building Room 2144, Charlottesville, VA 22908-1363; e-mail: (email@example.com).
Terms such as “global health,” “international health,” or “tropical medicine” are evasive and do not fit into geographic, climatic, or infectious disease pigeonholes. “Global health” is increasingly used to stress the global commonality of health issues that transcend national borders, class, race, ethnicity, income, or culture. Although disease patterns vary geographically, the conditions that foster disease onset such as poverty, limited access to health care, the status of women, environmental degradation, political instability, war, and genetic susceptibility are often the same worldwide. The rise of chronic conditions of the industrialized world in rapidly developing countries, such as cardiovascular disease, lung disease due to smoking, and diabetes mellitus, highlights our sameness again. The Director General of the World Health Organization (WHO) summarized it best: “In the past, desperate conditions on another continent might cynically be written out of one’s memory. The process of globalization has made such an option impossible. The separation between domestic and international health problems is no longer useful.”1
Global Health Competencies
If global health issues are to be fruitfully addressed, the medical community must ask itself: What do U.S. and Canadian medical students need to know to be competent in improving global health? One’s answer will depend on one’s philosophy of how theoretical versus practice-oriented medical education should be. Ultimately, the answer rests on the medical school faculty, because it is they who are charged by the Liaison Committee on Medical Education (LCME) or the Committee on Accreditation of Canadian Medical Schools to determine the coverage and depth of topics in their medical school’s curriculum. Accordingly, we will not prescribe a specific curriculum herein, but we will describe the rationale for three core domains of global health competency that we feel provide meaningful coverage for all students: global burden of disease, traveler’s medicine, and immigrant health. Our recommendations stem from our work with the American Society for Tropical Medicine and Hygiene Committee on Medical Education and from discussions with the Global Health Education Consortium, which helped to abstractly inform the three competencies.
Competency domain 1: Burden of global diseases
We propose that every medical student should carry a basic understanding of the major diseases that affect humans worldwide. Just as basic science education in disciplines such as biochemistry and physiology is required by the LCME to inform students of pathogenesis of disease, we argue that knowledge of the major diseases that affect and kill people worldwide serves to inform the host, environmental, and systems-based factors that govern health worldwide. The annual World Health Report2 is one key resource of global health epidemiology that presents estimates of global mortality and disability-adjusted life years (DALY), a disease-specific measure that incorporates time lost from both premature mortality and disability (Figure 1). By learning, for example, that an entirely preventable disease such as measles accounts for almost 2% of the developing world’s DALY burden, students can appreciate how health system factors and myriad other factors conspire to impede the delivery of cost-effective vaccination services. For those who favor practice-oriented education, knowledge of the global patterns of disease remains critically important for informing what care is provided to travelers and immigrants.
Competency domain 2: Traveler’s medicine
Over 808 million persons crossed international borders in 2005, and this figure is projected to increase at a +4.1% rate.3 More than 28 million U.S. residents traveled overseas in 2005, 51% of whom were destined for the developing world (Figure 1).4 According to prior estimates, whereby 8 of every 100 travelers seek medical care,5 U.S. physicians may see as many 1.1 million returning travelers from the developing world each year, a number that will continue rise.
What, then, should every medical student learn about traveler’s medicine? First, it is unrealistic to propose that every student can learn the large and changing body of traveler’s medicine, which has emerged as an independent field with its own textbooks, specialists, and examination. We therefore sought input from the American Committee on Clinical Tropical Medicine and Travelers’ Health (ACCTMTH), the parent organization for this specialty. During 2005, voluntary online questionnaires were sent to the approximately 500 ACCTMTH members. Replies were received from 132 members, 74% of whom identified themselves as past or present teachers in North American medical schools. We posed two major questions: how many hours should be dedicated to medical school curricula in tropical medicine and traveler’s health, and how should this time be distributed? Next, we asked respondents to prioritize a list of topics taken from the outline of testable material from the ACCTMTH certification examination (www.astmh.org/certification). ACCTMTH respondents felt that, ideally, a median of 30 hours (mean 45.8 hours; 95% confidence interval, 36.0–55.5) should be dedicated to tropical medicine topics in the course of undergraduate medical education. Malaria was highlighted as the most deserving subject (2.8 ± 0.1 hours out of 30, P < .05), followed by tropical disease clinical syndromes (2.4 ± 0.1 hours), global health epidemiology (2.4 ± 0.1 hours), global HIV and tuberculosis (2.2 ± 0.1 hours), and intestinal protozoa (2.0 ± 0.1 hours). An anecdote that illustrates the importance of a basic cognizance of malaria is the experience of Lt. Cmdr. John Newman, a general surgeon, who at the microscope in 2003 made the life-saving diagnosis of Plasmodium falciparum malaria when U.S. Marines presented atypically in Liberia.6
Competency domain 3: Immigrant health
The third basic global health domain involves the health care of the increasing immigrant population of the United States and Canada. The foreign-born population of the United States rose from 7.9% in 1990 to 12.1% in 2000.7 Of 946,142 immigrants to the United States in 2004, 77.7% were from WHO-defined developing countries8 (Figure 2). These figures exclude refugees, those seeking asylum, and an estimated 11.1 million illegal immigrants.9 Toronto leads North American cities in foreign-born residents, with fully 43% of its population born in foreign countries.10 The challenge of immigration is not only an issue for urban medical schools. Certain counties in Kansas, Idaho, and Washington states share high rates of foreign-born residents, and Minnesota has the highest per capita concentration of Laotians in the United States. The foreign-born populations of North Carolina, Georgia, and Nevada have more than tripled during the 1990s.7 To provide health care for this changing population, independent of the political debate on how to fund it for those who reside illegally, future physicians must be familiar with the spectrum of diseases such changes are likely to bring. A key public health example is tuberculosis, where 53.5% of U.S. cases are foreign- born patients and tuberculin skin testing of recent immigrants is a key guideline for control.11,12 Culturally competent care is another basic requirement for the proper health care of immigrants (and minorities in general) that has recently received attention from the Association of American Medical Colleges (AAMC).13
Student Interest in Global Health
Regardless of faculty opinion on a global health curriculum, medical students are highly interested in the topic of global health, and we must listen to their views as the consumers and purchasers of medical education. The American Medical Students Association has formed a Global Health Action Committee, and Canadian students operate a Student University Network for Social and International Health. In the “other comments” section of the ACCTMH survey we administered, repeated mention was made that advanced electives for students in global health-related topics were popular and filled to capacity. One measure of this interest is medical students’ participation in international electives, which has averaged a robust 23.1% among U.S. graduates since 200014 not including those who participated in cultural awareness workshops, multicultural community-based projects, or learned a foreign language for patient care (Figure 3). The educational needs and benefits of this highly interested and increasing group of students participating in international electives are significant, and have appropriately received some attention from the AAMC as well as the published literature.15–17 Indeed, largely fed by student interest, some schools have created explicit international health tracks and curricula (Baylor University and Columbia University are but two examples18). Importantly, however, schools need to separate the educational needs of the highly interested group of students who participate in global health electives from the core competency in global health needed by all. These latter educational requirements are particularly in need of attention. Medical schools in the United Kingdom, Sweden, and the Netherlands appear to be addressing this educational component already.19
The Future of Global Health Education
We are keenly aware that U.S. and Canadian medical school curriculum committees are under tremendous pressure to balance changing educational content and new styles of learning. We know that a 30-hour global health curriculum, either as a stand-alone course or with the equivalent hours incorporated into existing courses, may not be possible for all schools. Yet, by ensuring that the existing curriculum covers at least these three domains, all students can achieve basic competency. Our charge is for all medical schools in the United States and Canada to reevaluate their global health curricula and for the LCME to establish a global health standard. This will ensure that we equip all graduates with the tools needed to treat patients in our changing and global health care environment.
The authors are indebted to the other members of the American Society for Tropical Medicine and Hygiene (ASTMH) Committee on Medical Education: David Freedman (University of Alabama, Birmingham, Ala), John Gawoski (Lahey Clinic, Burlington, Mass), Devon Hale (University of Utah, Salt Lake City, Utah), Sandy Hoar (George Washington University, Washington, DC), Gregory J. Martin (Naval Medical Research Center, Lima, Peru), Anne McCarthy (University of Ottawa, Ottawa, Canada), Dick MacLean (McGill University, Montreal, Canada), and Joseph Sliman (Navy Environmental and Preventive Medicine Unit 6, Pearl Harbor, Hawaii).
The views expressed in this article are those of the authors and do not necessarily represent those of the American Society of Tropical Medicine and Hygiene, the American Committee on Clinical Tropical Medicine and Travelers’ Health, or the Global Health Education Consortium.
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8 Department of Homeland Security. Yearbook of Immigration Statistics. Washington, DC: Department of Homeland Security; 2004.
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12 American Thoracic Society; Centers for Disease Control and Prevention; Infectious Diseases Society of America. Controlling tuberculosis in the United States. Am J Respir Crit Care Med. 2005;172:1169–1227.
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