Saba, Nicole MSc; Brewer, Timothy F. MD, MPH
Through influences that extend beyond the familiar grounds of public health and medicine, globalization has profoundly altered both the determinants of health and the delivery of health care. Global environmental changes; international trade agreements; and other social and economic forces, especially the rapid, worldwide movement of people, pathogens, and produce, are increasingly recognized as playing pivotal roles in health and access to health care.1–3 Substantial changes are also occurring in the supply of medical providers, with the large-scale migration of physicians from low-resource settings to countries such as the United States and Canada. Between 23% and 28% of medical graduates in developed countries have been trained internationally. Of these international medical graduates, between 40% and 75% are trained in low-income countries such as India, the Philippines, and Pakistan.4 The migration of physicians from low-resource countries calls for approaches that support health care workers remaining in their countries while building new capacity in these places. In addition to these factors, in medical schools, student interest in international electives has been consistently increasing over the past decade5; in 2006, 27% of North American medical students participated in an overseas elective.6
The need for a new paradigm in global health has been increasingly recognized by governments, funding agencies and foundations, investigators, and students. For example, during the past seven years, Canada has committed nearly a billion of its dollars to HIV/AIDS programs and health care capacity building in developing countries.7,8 Unfortunately, these substantial efforts by the Canadian government have not been matched by medical school training programs, despite the tremendous interest among students. Global health training in Canadian medical schools ranges from essentially no training at all to extensive elective courses that include didactic lectures and internationally based placements. Expanding global health educational opportunities is hampered by a lack of educational resources, trained faculty, and institutional support.9 Addressing these obstacles is a goal of the Global Health Programs (GHP) at McGill University Faculty of Medicine.
McGill’s GHP evolved from the international health office (IHO) of the faculty of medicine. Founded around 1987, the IHO sprang out of projects to train community health managers in Ethiopia and the former Soviet Union. During a nine-year period, the McGill Ethiopia Community Health Project trained approximately 150 individuals in short-term courses, 80 master-level health care professionals, and 15 doctoral-level graduates. Applying lessons learned from these projects, the IHO established important principles for working in international health, including an emphasis on collaborative partnerships, capacity building, and working on projects that address local needs.
In recent years, there has been a trend among researchers, health care workers, public health officials, and others to move from international health to global health, recognizing that today’s major health issues transcend national borders. In addition, the U.S. Institute of Medicine has defined global health as “health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.”10 In keeping with this new understanding, the IHO was renamed Global Health Programs in 2005.
As members of a global society of committed educators, scientists, health care workers, and students, the McGill community appreciates that we have much to learn from our peers about, as well as much to contribute to, addressing the major health challenges of our time. GHP recognizes in its mission this commonality and the need for true partnerships among colleagues in global health.
The mission of McGill’s GHP is to
* establish and facilitate international research collaborations to address leading health challenges,
* support the training of health care workers and researchers to combat global health disparities,
* support students and faculty to work with underserved populations and in underserved regions,
* promote long-term capacity building in health and health-related sciences in low-resource areas, and
* attract outstanding individuals into global-health-related fields.11
Using a variety of approaches and activities (described below), we fulfill our mission by (1) strengthening research and teaching capacity in global health, (2) building partnerships across disciplines, institutions, and countries, (3) improving medical education, and (4) identifying resources and opportunities (see Table 1).
Strengthening Research and Teaching Capacity at McGill University
Beyond Borders: An interdisciplinary conference
Establishing and enhancing institutional research and teaching capacity are at the center of building any global health program. We have accomplished this goal by identifying assets that already exist within the faculty and student body as well as barriers that may inhibit the exchange of global health knowledge and information across departments and disciplines. In a joint collaboration with the McGill Institute for Health and Social Policy, we organized a conference to bring together outstanding educators and scientists from throughout the university to discuss approaches for improving interdisciplinary teaching and research capacity in global health and social policy. By having faculty and students from liberal arts, law, medicine, nursing, nutrition, agriculture, and environment discuss shared interests and goals together, it was possible to efficiently recognize opportunities for facilitating new collaborations and projects. Difficulties in working across schools and fields were also identified, allowing for possible solutions. University-based panelists were supplemented with well-known outside participants from other universities, funding agencies, and the Canadian government, who helped stimulate interest in this first-ever McGill conference. For example, Dr. Allan Ronald, distinguished professor emeritus at the University of Manitoba, shared his 30 years’ experience in building research and training programs in developing countries; and Dr. Ron Labonte, Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, described the opportunities and challenges globalization is creating in health care research. Dr. Carolyn Bennett, MP, and former minister of state for public health for Canada, concluded the conference with a keynote address on health versus health care: Putting the “public” back in “public health.”
Conference participants grappled with practical questions from real experiences such as How does one keep specialized refrigerators running in environments where frequent interruptions in electrical services occur? and What are possible options when the local police or army in another country confiscates years’ worth of data and samples? These specific questions were balanced in the conference with broader discussions on topics such as how to involve local communities in study design and how to educate governmental officials about ways of using research to advance public policy. Identifying commonalities, recognizing where new approaches may be needed, and linking individuals interested in many different aspects of global health were all important goals of the conference. For example, how do lessons learned developing a nutritional program for Inuit in Northern Québec help survey researchers investigate HIV transmission in sexually active adolescents in Malawi? How does a university facilitate interactions between researchers in the departments of agriculture and sociology so that this knowledge may be shared? To have a more complete understanding of such complex subjects, it is beneficial to consider different perspectives. Bringing faculty from different parts of the university together to learn from each other’s experiences is one start.
To allow lessons learned at this conference to be distributed as widely as possible, videos of conference presentations were available online at the McGill GHP Web site (http://www.mcgill.ca/globalhealth/conference2007). Response to this initial conference was so positive that we are seeking resources to establish an annual global health conference program.
Library resources, presentations, and courses
The interdisciplinary conference was just one step towards improving research and teaching at McGill University. Another challenge to stimulating global health research and educational activities was the lack of clearly defined resources for conducting the literature searches helpful for beginning new projects and courses. To overcome this obstacle, we worked with the McGill Institute for Health and Social Policy and the McGill University Libraries to identify textbooks, journals, and electronic-based resources to aid educators and researchers in developing their curricula and projects. These global health resources, organized by content and topic, were brought together on the Health Sciences Library Web site (http://www.health.library.mcgill.ca/research/sguides/globalhealth/index.cfm), where they are freely available.12 More recently, we have been developing a system that allows faculty members to upload additional global health resources, such as presentations and course materials.
Building Partnerships for Health and Education
Collaborative, international partnerships lie at the heart of any global health program, and we have endeavored to stimulate and nurture these partnerships. McGill University has more than 75 international partnerships with universities, health care institutions, nongovernmental organizations, and others to conduct research as well as educational, capacity-building, clinical, and community service projects. One example of how strong collaborative partnerships can facilitate opportunities is the range of projects shared between investigators at McGill and those at Universidad Peruana Cayetano Heredia in Lima, Peru.
This partnership began with investigators at the two universities studying the treatment of cutaneous leishmanisis. From this initial project, additional opportunities have grown with other faculty at the two institutions, including joint initiatives investigating stigma associated with mental illness, the prevention and control of multiple-drug-resistant tuberculosis and hookworm, and the surveillance of emerging diseases. Although there is no single way to build global health partnerships, invested individual faculty at the two institutions who share interests, respect, and trust have been crucial to nurturing this relationship. These individual endeavors have led to university-level discussions about the possibility of student and faculty exchanges.
To stimulate partnerships between Canadian universities and their counterparts in low-resource settings, the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, and the International Development Research Centre recently came together to form the Global Health Research Initiative (GHRI).13 The GHRI established the Teasdale-Corti Grant Program, a prestigious and highly competitive program that funded 13 programs in all fields of health in developed as well as developing countries.
Improving Global Health Education at Canadian Medical Schools
In an era of globalization and unprecedented migration, immigrants accounted for 18.4% of the total Canadian population in 2001; in the city of Toronto, almost 44% of residents were foreign born.14 Medical education needs to adapt to these forces that are now shaping health and health care, as well as to the changing patient population of our increasingly diverse communities. To better prepare medical students for this new environment, we are acting locally within McGill and with colleagues across Canada to improve global health educational opportunities at the institutional and the national levels.
Through the Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health, we undertook a survey of global health education and training opportunities at the 17 Canadian medical schools in 2005–2006. Results showed that there exists wide variation in educational offerings across medicals schools, with no consensus on what global health knowledge and skills medical students require.9 This disparity in educational offerings is a major barrier to developing comprehensive and standard global health training suitable for a medical curriculum. The resource group under GHP leadership has not only expanded the application of the Institute of Medicine’s global health definition (noted at the beginning of this article) to encompass political, economic, and social dynamics as well as disease, but has also identified core competency areas that are felt to be the foundation for a global health curriculum. These competency areas are
* the global burden of disease;
* the migration, movement, and marginalization of people;
* the effect of globalization on health and health systems;
* social and environmental determinants of health; and
* health care in low-resource settings.
These competency areas overlap, but are not identical to, those recently suggested by others.5 GHP and the AFMC Resource Group are defining the knowledge and skills ideally obtained under each of these competency areas.
Locally, we are collaborating with McGill faculty and students to introduce global health topics within our curricula and to establish supervised international experiences for students. Specifically, GHP has set up a team to adapt our preclinical medical school curriculum to include global health issues. For example, instead of having students learn test sensitivity and specificity from studies of CT scans used to diagnose acute appendicitis, we teach these same two concepts using studies of circumcision for HIV prevention. Supplemental information and resources are provided to enable students to learn more about the global burden of HIV and AIDS as well as current issues in the prevention and treatment of these diseases without requiring additional time in the curriculum.
To facilitate the utility and effectiveness of global health educational materials, GHP is collaborating with the McGill Molson Medical Informatics group to create Web-based educational resources to supplement our standard medical curriculum. Once developed and implemented, these Internet resources can be expanded and adapted for use by partners in low-income countries.
The opportunities to enhance medical education locally and internationally are endless and intertwined.
Creating Resources and Opportunities for Faculty and Students
Repository of activities of McGill’s GHP
Building McGill’s global health activities required an awareness of the programs, resources, and expertise already in place. However, information about international activities was not easily available to faculty and students, posing a substantial barrier to building McGill’s global health portfolio. To address this obstacle, we created a repository of all global health activities undertaken by McGill faculty in a user-friendly, interactive map of the world (see Tables 2 and 3, and Figure 1). This database has proven to be effective in stimulating faculty partnerships as well as serving as a means by which students learn about projects and possible mentors while formulating career choices. Since its launch in 2006, more than 150 projects in approximately 60 countries have been identified and entered from across both McGill campuses; we anticipate the numbers will continue to rise and spark interest among faculty and students.
In addition to facilitating awareness and communication within our own institution, the repository has increased external recognition of McGill’s areas of global health expertise. For example, the Web site led to discussions among international organizations, McGill faculty, and governments in the Latin American region about initiating a multinational project to combat childhood malnutrition.
Mentoring, advising, and supporting faculty and students
As interest in global health expands among students and faculty, so too does the challenge of ensuring that emerging activities are ethical and educational while they also meet the needs of local and international partners. Because interest may exceed expertise, an important task for our program is to advise and support McGill faculty, staff, and students who are developing potential global health projects. At the faculty level, we have advised and assisted departments in planning internationally based training sites and hospital administrators in engaging in overseas consultation programs.
McGill has very active student-run global health organizations, including the McGill International Health Initiative and the International Federation of Medical Students’ Associations–Quebec Division. Between them, these organizations run a scholarship program, the Osler Medical Aid Foundation, to support international electives; a predeparture program to prepare students across the province for international experiences; and a simulated World Health Organization conference to increase students’ understanding of politics and government in global health issues.15 The goals and objectives of these programs are determined by the students, though faculty provide consultative and financial support for their activities. Besides supporting student-initiated programs, faculty provide individual academic advising regarding global health care classes and opportunities for both current and prospective students.
The Osler scholarships enable students to work in low-income clinical settings overseas. The students use this program to increase their interest in global health activities, to foster their awareness of health care conditions in low-resource settings, and as opportunities for personal growth. Although many McGill students have rewarding overseas experiences, the faculty at McGill, like at most medical schools, are still working to insure that students are adequately prepared for international electives and that elective sites are able to meet the students’ educational needs.9
Although each medical school has unique expertise and resources, themes emerged from the development of McGill’s GHP that are likely to be applicable to other institutions. Lack of awareness of the diverse projects and activities among faculty and students is a major stumbling block to building global health programs. Additionally, if information about grants, projects, and programs is not readily accessible to all (even if it is in a central administration office), the information neither promotes awareness nor facilitates collaborations. Therefore, a central repository of this information should be created and made publicly available. Fostering communication and collaboration within and among departments, faculty, and students is crucial to any successful global health program.
Building on the institution’s strengths and keeping the initial activities focused are also important. Before the initiation of GHP at McGill, a number of individual investigators there were already independently working with colleagues at Universidad Peruana Cayetano Heredia in Peru. These previously established relationships formed a natural base on which to initiate a more comprehensive partnership. Global health incorporates a gamut of expertise and activities; many organizations have been involved in global health activities for a long time. Building off existing projects and collaborations allows new global health programs to take advantage of experience and knowledge already in place. That, together with concentrating on a few initial objectives, increases chances for success.
Someone, preferably a senior faculty member or administrator, should be given resources (staff, operating budget) to initiate and support global health programs and then be held responsible for the programs’ conduct, strategic planning, and future funding.1 In addition, by making a clear statement concerning global health’s role in institutional priorities and by providing support for this commitment (although much may be accomplished with relatively modest financial support), medical school deans increase the likelihood of having successful programs for their faculty and students.
Finally, schools should take advantage of students’ energy and enthusiasm. There is a large and growing interest among medical students for global health educational programs; they can be essential partners in developing programs, raising awareness, and advocating for change within the faculty and the school.
Continuing a Tradition
McGill fortunately had already established a tradition of conducting international training programs, a faculty with ongoing overseas research projects, and a student body committed to and enthusiastic about global health. With support from the dean’s office and the identification of a faculty member responsible for global health activities, building on these assets to establish a dynamic and growing global health program has been possible. In doing so, our faculty and students are better positioned to work with partners across the globe to improve health throughout Québec, Canada, and the world.